aging is associated with an increased risk of developing respiratory impairment1 . after a stroke , respiratory function
lung function tests are not 
 necessarily conducted in rehabilitation , sometimes because there is no examination 
 equipment .
( mainly for the pectoralis major muscle ) is to 
 improves the ratio of dyspnea in chronic obstructive pulmonary disease with respiratory 
 dysfunction .
therefore , it appears thought that the shoulder joint horizontal adductor 
 muscles on the rib cage are involved in respiratory function .
shoulder joint horizontal 
 adductor muscle strength measurements could be used as an alternative evaluation of cases 
 for whom lung function tests are difficult .
accordingly , this study examined a measurement 
 method of shoulder joint horizontal adductor muscle strength using geriatric and stroke 
 patients .
muscle strength measurements using a handheld dynamometer ( hhd ) consist of two types : a 
  make test  and a  break test .
 one limitation of using an hhd is that the make test can not 
 measure the maximum muscle strength of a subject if the examiner can not resist the subject s 
 movement .
another limitation of an hhd is that the break test can not measure the maximum 
 muscle strength of a subject if the subject can not maintain the position .
previous studies 
 have reported that 30  kg ( 300 n ) is the fixed limit for an hhd in the make test4 , 5 . 

katoh et al . devised a method of using a belt as a countermeasure to the fixed hhd limit 
 when measuring lower limbs with high muscle strength values and reported on the reliability 
 of this method for a variety of subjects6,7,8,9 .
our research group has also reported on the 
 usefulness of the belt with a fixed hhd limit for shoulder joint horizontal adductor muscle 
 strength measurements of young healthy japanese adults10 and its reliability11 .
however , the reliability of this method in the measurement of 
 geriatric and non - healthy individuals has not yet been reported .
few measurements and high 
 reliability are necessary to reduce the patient burden in the evaluation of geriatric 
 patients and stroke patients presenting with motor paralysis .
the purpose of this study was 
 to examine the appropriate number of measurements and the intrarater reliabilities of 
 shoulder joint horizontal adductor muscle strength measurements using an hhd with a belt for 
 geriatric and stroke patients .
the subjects were 40 inpatients over the age of 65  years ( onset days , 3103 ) .
they were 
 divided into two groups : 20 stroke patients in the stroke group ( sg ) , and 20 geriatric 
 patients in the no - stroke group ( n - sg ) .
subjects were included in the sg only if the 
 movement of shoulder joint horizontal adduction was possible with a japanese coma scale 
 ( jcs ) score of 1 . subjects were included in n - sg if neurological and orthopedic 
 abnormalities were absent from the upper limbs .
table 
 1table 1.general and medical characteristics of subjects 
 sg ( n=20)n - sg ( n=20)gender ( male , female)(14,6)(11,9)age ( years)75.06.6 ( 6684)80.26.2 ( 6791)height ( cm)159.210.3 ( 136178)152.28.5 ( 137170)body weight ( kg)58.312.6 ( 4281)47.79.7 ( 3164)onset dates ( days)13.810.4 ( 341)24.824.6 ( 5103)disease statedisease stateintracerebral hemorrhage4pneumonia9cerebral infarction12pelvic fracture1subdural hemorrhage3spinal compression fracture4hemorrhagic infarction 1bruise of head or general body2paralyzed side ( right / left)12/8dehydration1sias knee - mouth test score57cancer1412acute renal failure131diabetes mellitus1200meansd ( range ) , sg : stroke group , n - sg : no - stroke group shows the subject characteristics .
meansd ( range ) , sg : stroke group , n - sg : no - stroke group all shoulder joint horizontal adductor muscle strength measurements were performed with the 
 subjects lying on an examination table in the supine position .
the shoulder joint of each 
 subject was abducted to 90 , with 0 internal and external rotation , and the elbow joint was 
 flexed to 90. the subject was positioned such that the shoulder joint was aligned with the 
 bedpost .
the elbow on the measurement side was positioned on the edge of the examination 
 table .
the equipment used for shoulder joint horizontal adductor muscle strength measurements was 
 a tas f-1 hhd ( anima corp . ,
the sensor was placed on a thin rubber pad , 
 which was fixed to the distal part of the upper arm with a surface fastener .
the belt was 
 fitted with sensors and inserted between the bedpost and the floor to fix the hhd .
the 
 examiner was a 32-year - old male physical therapist , 168  cm in height and 60  kg in weight , 
 with 10-year - experience .
the examiner controlled his hand in such a way so as not to move 
 the hhd sensor and placed his other hand on the anterior aspect of the opposite shoulder 
 joint to suppress compensatory movements .
subjects were asked to perform isometric contractions in 
 a manner similar to the make test .
maximum contractions were attained within 3  s and were 
 maintained for 5 s. the maximum values of shoulder joint horizontal adductor muscle strength 
 were recorded .
all measurements were performed after practice and prior orientation . in 
 addition , all measurements were performed on the same day , three consecutive times on each 
 side , at 30-s intervals .
measurering method ( image ) reliability was verified using three measurements , the maximum value obtained during the 
 first and second measurements and the maximum value obtained during the first and second 
 measurements and the third measurement .
the difference in mean values was assessed using one - way analysis of 
 variance with the scheffe multiple comparison procedure .
reliability was verified using 
 intrarater reliability as assessed by the intraclass correlation coefficient ( icc ) ( 1 , 1 ) 
 and bland - altman analysis ( baa ) .
baa was performed using the first and second measurements as 
 well as the maximum value obtained during the first and second measurements and the third 
 measurement . a probability ( p ) value of < 0.05 was considered to be statistically 
 significant .
the study protocol was approved by the ethics committee of ryotokuji university ( approval 
 number : 2632 ) and was in accordance with the declaration of helsinki .
the mean and standard deviation of shoulder joint horizontal adductor muscle strength 
 measurements are shown in table 
 2table 2.shoulder joint horizontal adductor muscle strength ( ratio muscle strength / body 
 weight)sg ( n=20)n - sg ( n=20)non - paralyzedsideparalyzedsiderightsideleftside1st ( kgf / kg)0.270.120.250.120.190.080.180.09 2nd ( kgf / kg)0.260.110.250.130.200.080.190.083rd ( kgf / kg)0.250.100.240.11 0.200.070.180.08the maximum value obtained during the 1st and 2nd ( kgf / kg)0.280.120.260.130.210.080.190.08 the maximum value ( kgf / kg)0.280.110.270.130.210.070.200.20meansd ( range ) , sg : stroke group , n - sg : no - stroke group : vs. the maximum value , p<0.05 , * : vs. the maximum value obtained 
 during the 1st and 2nd , p>0.05no significant difference between the non - paralyzed side vs. paralyzed side , and 
 between the right side vs. left side .. the results of icc ( 1 , 1 ) were 0.92 ( table 3table 3.icc of shoulder joint horizontal adductor muscle strengthgroupmeasurement sideicc ( 11)95%cisgnon - paralyzed0.937 0.8740.972 
 paralyzed0.920 0.8430.965n - sgright0.930 0.8610.969 
 left0.943 0.8860.975sg : stroke group , n - sg : no - stroke group , icc ( 1,1 ) : intra - rater correlation 
 coefficients , 95% ci : 95% confidence interval ) .
the results of baa are shown in table 
 4table 4.bland-altman analysis of shoulder joint horizontal adductor muscle strength 
 measurementsgroupmeasurement sidecomparisonfixed biasproportional biasloamdc95 ( kgf / kg)95 cibias*slope of the regression linebias*sg ( n=20)non - paralyzeda0.01 to 0.03n - ex 0.033 n - ex0.03 to 0.060.08 b0.01 to 0.04ex0.166 ex0.02 to 0.070.08 paralyzeda0.02 to 0.01n - ex0.016n - ex0.04 to 0.040.07 b0.001 to 0.05n - ex0.152 n - ex0.03 to 0.090.10
n - sg ( n=20)righta0.03 to 0.001ex0.011 n - ex0.04 to 0.020.05 b0.002 to 0.02n - ex0.142n - ex0.02 to 0.030.05 lefta0.02 to 0.01n - ex0.122n - ex0.04 to 0.030.06 b0.001 to 0.02ex0.071n - ex0.01 to 0.040.04 sg : stroke group , n - sg : non - stroke group , a : comparison is a the 1st and 2nd 
 measurements , b : the maximum obtained during the 1st and 2nd measurements and the 3rd 
 measurrment , loa : limits of agreement , mdc95 : minimal detectable change 
 95% . * : exsist : bias is present , n - ex : not present . in sg , there was no systematic bias on either side between the first and 
 second measurement values .
the third measurement value was smaller than the maximum value 
 obtained during the first and second measurements . in n - sg
, a systematic bias was observed 
 between the first and second measurement values on the right side .
however , no systematic 
 bias was observed between the maximum value obtained during the first and second 
 measurements and the third measurement value , and no systematic bias was observed between 
 the first and second measurement values on the left side . on both sides ,
the third 
 measurement value was smaller than the maximum value obtained during the first and second 
 measurements .
meansd ( range ) , sg : stroke group , n - sg : no - stroke group : vs. the maximum value , p<0.05 , * : vs. the maximum value obtained 
 during the 1st and 2nd , p>0.05 no significant difference between the non - paralyzed side vs. paralyzed side , and 
 between the right side vs. left side .
sg : stroke group , n - sg : no - stroke group , icc ( 1,1 ) : intra - rater correlation 
 coefficients , 95% ci : 95% confidence interval sg : stroke group , n - sg : non - stroke group , a : comparison is a the 1st and 2nd 
 measurements , b : the maximum obtained during the 1st and 2nd measurements and the 3rd 
 measurrment , loa : limits of agreement , mdc95 : minimal detectable change 
 95% . * : exsist : bias is present , n - ex : not present
the results of this present study indicate that in sg , icc ( 1 , 1 ) of relative reliability 
 was high at 0.920.94 .
the results of baa of absolute reliability indicate that there was no 
 systematic bias on either the non - paralyzed side or the paralyzed side between the first and 
 second measurement values .
in addition , the maximum value obtained during the first and 
 second measurements was greater than that obtained during the first measurement .
therefore , 
 these results suggest that when evaluating stroke patients , the required number of 
 measurements is two for the maximum value of the first and second measurements .
in addition , 
 the minimal detectable change in the 95% confidence interval ( mdc95 ) on the 
 non - paralyzed side was 0.08 kgf / kg , and 0.07 kgf / kg on the paralyzed side . in n - sg , icc ( 1 , 1 ) of relative reliability was high at 0.930.94 .
the results of baa of 
 absolute reliability indicate there was a systemic bias between the first and second 
 measurement values on the right side .
no systematic bias was found between the maximum value 
 obtained during the first and second measurements and the third measurement or between the 
 first and second measurement values on the left side . in n - sg , for both sides , the third 
 measurement value was smaller than the maximum value obtained during the first and second 
 measurements .
therefore , these results suggest that when evaluating geriatric patients , the 
 required number of measurements is two for the maximum value of the first and second 
 measurements .
in addition , mdc95 on the right side was 0.05 kgf / kg , and 0.06 
 kgf / kg on the left side . in a study on the reliability of knee extension strength measurements ,
katoh et al.8 suggested that the first measurement value 
 or the average value of two measurements could not be used because the icc ( 1 , 1 ) of 
 measurements using an hhd with a belt was 0.820.92 , and sometimes , the second measurement 
 value was greater than the first measurement value .
in addition , based on the results of 
 absolute reliability in knee extension strength measurements , they reported that the 
 required number of measurements was three9 .
in contrast , in a study of the reliability of muscle strength 
 measurements made with an hhd of the upper extremity , schrama et al.12 reported that the intrarater reliability of an hhd in the 
 assessment of the upper limb muscle strength of healthy subjects was acceptable only for 
 elbow measurements .
hirano et al.11 
 examined young healthy adults to establish the absolute reliability of shoulder joint 
 horizontal adductor muscle strength measurements and observed a systematic bias between the 
 maximum value obtained during the first and second measurements and the third measurement . 

the third measurement was smaller than the maximum value obtained during the first and 
 second measurements . as these results showed the limits of agreement ( loa ) , they recommended 
 that the maximum value of two measurements should be used . based on our findings ,
the 
 relative reliability of shoulder joint horizontal adductor muscle strength measurements of 
 hospitalized geriatric and stroke patients was as high as 0.920.94 .
similar to previous 
 studies , and considering our results of absolute reliability , it is our recommendation that 
 the adopted values should be the maximum value of two measurements .
in addition , to help 
 with the interpretation of the determined effects , mdc95 was evaluated and found 
 to be 0.08 kgf / kg in sg and 0.06
the present study investigated the reliability of shoulder joint horizontal adduction 
 muscle strength measurements of hospitalized patients .
the appropriate number of 
 measurements of shoulder joint horizontal adductor muscle strength measurements was two for 
 geriatric and stroke patients .
however , the present study had a limitation in that it did 
 not validate the interrater reliability .
future studies to investigate the relevance of 
 shoulder joint horizontal adductor muscle strength measurements in relation to activities of 
 daily living and respiratory function of geriatric patients and stroke patients will help to 
 clarify the potential clinical application of the present findings .
 [ purpose ] this study aimed to verify the appropriate number of measurements and the 
 intrarater reliabilities of shoulder joint horizontal adductor muscle strength 
 measurements using a handheld dynamometer ( hhd ) for geriatric and stroke patients . 
 
 [ subjects and methods ] the subjects were 40 inpatients , who were divided into two groups : 
 20 stroke patients in the stroke group ( sg ) , and 20 geriatric patients in the no - stroke 
 group ( n - sg ) . 
 measurements were performed three times using an hhd with a belt . 
 the 
 reliability was verified using bland - altman analysis and the intraclass correlation 
 coefficient ( icc ) . 
 [ results ] icc ( 1 , 1 ) was > 0.9 . 
 a systematic bias was not observed 
 between the first and second measurement values except for the right side in n - sg . 
 a 
 systematic bias between the maximum value obtained during the first and second 
 measurements and third measurement value was observed on the left side in n - sg , and on the 
 non - paralyzed side in sg : the third measurement values were small in both cases . 
 
 [ conclusion ] intrarater reliabilities were high for shoulder horizontal adductor strength 
 measurements using an hhd with a belt for geriatric and stroke patients . taking the 
 systematic bias into consideration , these findings suggest that the required number of 
 measurements is two . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION