The enhanced paper grip test can substantially improve community screening for the risk of falling

Background
Lower-limb strength measures can enhance falls risk assessment but due to the lack of clinically applicable methods, such measures are not included in current screening. The enhanced paper grip test (EPGT) is a simple-to-use and cost-effective test that could fill this gap. However, its outcome measure (EPGT force) has not yet been directly linked to the risk of falling.

Research question
Is the EPGT a good candidate for falls risk screening in older people in the community?

Methods
Seventy-one older people living independently in the community were recruited for this prospective observational study (median age 69 y, range 65y-79y). Lower-limb and whole-body strength were assessed at baseline using the EPGT and a standardised hand-grip method respectively. Incident falls were recorded monthly for a year through follow-up telephone conversations. The capacity of individual strength measures to predict falls and to enhance an established falls risk assessment tool (FRAT) commonly used by UK’s national health service (NHS) was assessed using binomial logistic regression. The analysis was repeated for the subset of participants without history of falling at baseline (prediction of first-ever falls).

Results
Increased EPGT force and increased symmetry in strength between limbs were significantly associated with reduced risk of falling. Compared to the NHS-FRAT, the EPGT correctly classified more people (73% vs 69%), it achieved higher sensitivity (56% vs 26%) and higher negative predictive value (76% vs 68%). Complementing the NHS-FRAT with the EPGT produced a more comprehensive model that correctly classified 91% of participants and achieved 98% specificity, 81% sensitivity, 89% negative and 96% positive predictive value. Replacing the EPGT with hand-grip strength consistently undermined prediction accuracy. The EPGT remained highly accurate when focused on the prediction of first-ever falls.

Significance
The EPGT can substantially enhance falls screening in the community. These results can also inform effective personalised strength exercise interventions.