Disabilities of the Arm, Shoulder and Hand (DASH)

Purpose

The Disabilities of the Arm, Shoulder and Hand (DASH) is a self-report questionnaire that measures disability and symptoms of upper limb musculoskeletal disorders.

In-Depth Review

Purpose of the measure

The Disabilities of the Arm, Shoulder and Hand (DASH) is a self-report questionnaire that measures physical function and symptoms of the upper limb. The DASH can be used for any joint and any musculoskeletal condition of the upper limb (Hudak et al., 1996; Veehof et al., 2002), which permits comparison across upper limb diagnoses (Atroshi et al., 2000). The DASH is intended for discriminative and evaluative purposes (Schmitt & Di Fabio, 2004).

The DASH demonstrates validityThe degree to which an assessment measures what it is supposed to measure.
and responsivenessThe ability of an instrument to detect clinically important change over time.
in proximal and distal upper limb disorders (Beaton et al., 2001). The DASH demonstrated better clinimetric properties than other shoulder disability questionnaires including the Simply Shoulder Test (SST), American Shoulder and Elbow Surgeons Standardised Shoulder assessment Form (ASES) and the Shoulder Pain and Disability Index (SPADI – Bot et al., 2004).

Available versions

The DASH was developed by the American Academy of Orthopedic Surgeons, the Council of the Musculoskeletal Specialty Societies, and the Institute for Work and Health as a region-specific instrument to measure patients’ perception of disability and symptoms associated with any joint or condition of the upper limb (Hudak et al., 1996; Veehof et al., 2002).

The third edition of the DASH has been recently published to incorporate the latest research and new information regarding cross-cultural use of the measure.

Features of the measure

Items:

The DASH consists of 30 items that measure: (a) physical function (21 items); (b) symptom severity (5 items); and (c) social or role function (4 items).

Ability to do the following activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
:

1. Open a tight or new jar
2. Write
3. Turn a key
4. Prepare a meal
5. Push open a heavy door
6. Place an object on a shelf above your head
7. Do heavy household chores (e.g. wash walls, wash floors)
8. Garden or do yard work
9. Make a bed
10. Carry a shopping bag or briefcase
11. Carry a heavy object (over 5kg)
12. Change a light bulb overhead
13. Wash or blow dry your hair
14. Wash your back
15. Put on a pullover sweater
16. Use a knife to cut food
17. Recreational activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
    that require little effort (e.g. card playing, knitting)
18. Recreational activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
    that require taking some force or impact through the arm, shoulder or hand (e.g. golf, hammering, tennis)
19. Recreational activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
    that require you to move the arm freely (Frisbee, badminton)
20. Managing transportation needs (getting from one place to another0
21. Sexual activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
    
22. Extent to which arm, shoulder or hand problems interfered with normal social activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
    with family, friends, neighbours or groups
23. Extent to which arm, shoulder or hand problems limited work or other regular daily activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
    

Severity of the following symptoms:

1. Arm, shoulder or hand pain
2. Arm, shoulder or hand pain when performing activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
   
3. Tingling
4. Weakness
5. Stiffness
6. Difficulty in sleeping
7. Impact on self-image

The DASH also includes two optional modules regarding work and sports/performing arts that investigate the individual’s difficulty:

1. Using the usual technique for the activity (work; sport/instrument)
2. Performing the activity due to arm, shoulder or hand pain
3. Performing the as well as he/she would like
4. Spending the usual amount of time on the activity

Scoring:

The most recent version of the DASH uses a 5-point Likert scaleLikert scaling is one type of response to items in a questionnaire or tool. For example, Likert scaling would have you rate an item such as “I am satisfied with the care I received” on a scale using a 1-to-5 response scale where:
• 1 = strongly disagree
• 2 = disagree
• 3 = undecided
• 4 = agree
• 5 = strongly agree
You will find various options and scaling methods for the number of response choices (1-to-7, 1-to-9, 0-to-4). Odd-numbered scales usually have a middle value that is labelled Neutral or Undecided. Some tools used forced-choice Likert scaling with an even number of responses and no middle neutral or undecided choice. that rates the individual’s difficulties the preceding week. Lower scores indicate no difficulty, limitations or symptoms whereas higher scores indicate inability to perform tasks or extreme difficulties or symptomatology.

Items 1 – 21	1 = no difficulty 2 = mild difficulty 3 = moderate difficulty 4 = severe difficulty 5 = unable
Item 22	1 = not at all 2 = slightly 3 = moderately 4 = quite a bit 5 = extremely
Item 23	1 = not limited at all 2 = slightly limited 3 = moderately limited 4 = very limited 5 = unable
Items 24 – 28	1 = none 2 = mild 3 = moderate 4 = severe 5 = extreme
Optional work and sports/performing arts modules:	1 = no difficulty 2 = mild difficulty 3 = moderate difficulty 4 = severe difficulty 5 = unable

The DASH total score is calculated as a percentage (0=no disability to 100=maximal disability), using the following calculation:

[(Sum of completed responses ÷ number of completed responses) – 1] x 25

The final score for each optional module is calculated as follows:

[(Sum of completed responses ÷ 4) – 1] x 25

Note: A DASH total score cannot be calculated if more than 3 items have not been answered. Total scores for the additional modules cannot be calculated if there are any missing items.

Where 3 or fewer items have been missed, missing responses are replaced by the mean value of the responses to other items before summing.

Please note that earlier versions of the DASH use a different scoring system.

What to consider before beginning:

A study by Ring et al. (2006) showed a strong correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the DASH and measures of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
(Center for Epidemiologic Studies – DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
) and anxiety (Pain Anxiety Symptoms Scale) in a sample of 235 patients with discrete hand problems (e.g. carpal tunnel syndrome, de Quervain tenosynovitis, lateral elbow pain, trigger finger, distal radial fracture). Subsequently, Lozano Calderon et al. (2010) conducted a study with 516 patients requiring hand surgery and adjusted DASH scores for the influence of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
. This resulted in a significant decrease in the mean and standard deviation of DASH scores, although the decrease in variation was small. There was a high correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between DASH and depression-adjusted DASH scores, indicating no notable benefit to adjusting DASH scores for depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
. Given the high incidence of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
among patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., consideration of the correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between disability and depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
should be considered when using the DASH.

Time:

The DASH takes approximately 5 minutes to administer with patients with musculoskeletal disorders (Bot et al., 2004). Administration with patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. may require more time and support materials.

Training requirements:

No specific training requirements are specified.

Equipment:

No specific equipment is required.

Alternative Forms of the Measure

The QuickDASH is an 11-item questionnaire that was developed from the DASH using a concept-retention’ approach (Beaton et al., 2005). The QuickDASH is comprised of the following items:

1. Open a tight or new jar
2. Do heavy household chores (e.g. wash walls, wash floors)
3. Carry a shopping bag or briefcase
4. Wash your back
5. Use a knife to cut food
6. Recreational activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
   that require taking some force or impact through the arm, shoulder or hand (e.g. golf, hammering, tennis)
7. Extent to which arm, shoulder or hand problems interfered with normal social activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
   with family, friends, neighbours or groups
8. Extent to which arm, shoulder or hand problems limited work or other regular daily activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
   
9. Arm, shoulder or hand pain
10. Tingling
11. Difficulty in sleeping

The QuickDASH also retains the optional work and sports/performing arts modules (Beaton et al., 2005).

Like the DASH, the QuickDASH uses a 5-point Likert rating scale and the total score is calculated as a percentage (0=no disability – 100=most severe disability). At least 10 of the 11 items must be completed for correct use. The QuickDASH demonstrates similar test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
, validityThe degree to which an assessment measures what it is supposed to measure.
and responsivenessThe ability of an instrument to detect clinically important change over time.
to the DASH and may demonstrate better precision in detecting different degrees of disability than the DASH. Although there is a high correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the QuickDASH and the DASH, an exact match between the numeric scores of the two assessments is not guaranteed (Beaton et al., 2005). Due to the smaller number of items, the QuickDASH is considered to be more efficient than the DASH (Beaton et al., 2005; Gummesson et al., 2006). However, the DASH is more suitable than the QuickDASH for use when monitoring"The process of checking the task over time for ‘quality control’ and the adjustment of behavior" (Stuss, 2009, p. 9-10)
arm pain and function over time in individual patients.

Client suitability

Can be used with:

• Individuals with upper limb musculoskeletal impairment.
• Due to limited research regarding patient acceptability, the DASH may be more suitable for patients with mild impairment.

Should not be used with:

• N/A

Languages of the measure

Approved translations have been made in the following languages:

• Afrikaans
• Arabic
• Armenian
• Chinese (Hong Kong)
• Chinese (Taiwan)
• Czech
• Danish
• Dutch
• English (Australia)
• English (Hong Kong)
• English (South Africa)
• Finnish
• French Canadian
• French
• German
• Greek
• Hebrew
• Hungarian
• Italian
• Japanese
• Korean
• Lithuanian
• Malay
• Norwegian
• Persian (Iran)
• Polish
• Portugese (Brazil)
• Portugese (Portugal)
• Romanian
• Russian
• Serbian
• Sinhala (Sri Lanka)
• Spanish (Argentina)
• Spanish (Puerto Rico)
• Spanish (Spain)
• Swedish
• Thai
• Turkish

Translations are also in progress for the following languages:

• Croatian
• Estonian
• Filipino
• Isi-Xhosa
• Latvian
• Malayalam
• Slovak
• Spanish (Chile)
• Spanish (Dominican Republic)
• Ukrainian

Summary

What does the tool measure?	Upper extremity disability and pain.
What types of clients can the tool be used for?	Individuals with musculoskeletal disorders of the upper limb.
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment
Time to administer	Five minutes.
Versions	DASH QuickDASH
Other Languages	Afrikaans, Arabic, Armenian, Chinese (Hong Kong), Chinese (Taiwan), Czech, Danish, Dutch, English (Australia), English (Hong Kong), English (South Africa), Finnish, French Canadian, French, German, Greek, Hebrew, Hungarian, Italian, Japanese, Korean, Lithuanian, Malay, Norwegian, Persian (Iran), Polish, Portugese (Brazil), Portugese (Portugal), Romanian, Russian, Serbian, Sinhala (Sri Lanka), Spanish (Argentina), Spanish (Puerto Rico), Spanish (Spain), Swedish, Thai, Turkish.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have reported on the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the DASH among patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Test-retest: No studies have reported on the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the DASH among patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Intra-rater: No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the DASH among patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Inter-rater: No studies have reported on the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the DASH among patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: The DASH was developed by item generation (clinical expert input, literature review and patient focus groups) and item reduction (expert review, and psychometric and clinimetric analysis). One study that examined the content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension. of the DASH in a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. suggested a disordered rating scale structure and item hierarchy that is not suitable for clinical use. Criterion: Concurrent: No studies have reported on the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the DASH among patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Predictive: No studies have reported on the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of the DASH among patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Construct: Convergent/Discriminant: One study reported moderate correlations between manual ability and pain. Known Groups: No studies have reported on the known-groups validityThe degree to which an assessment measures what it is supposed to measure. of the DASH among patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Floor/Ceiling Effects	No studies have reported on the floor/ceiling effects of the DASH among patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Does the tool detect change in patients?	No studies have reported on the responsivenessThe ability of an instrument to detect clinically important change over time. among patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Acceptability	The DASH is simple to comprehend, quick to complete and is comprised of real-life, non-gender specific items. Due to limited research regarding patient acceptance, this tool may be more suitable for patients with mild impairment.
Feasibility	The DASH is a versatile measure that can be used for clinical or research purposes. However there is insufficient research regarding use of the DASH with patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and concerns that without testing, the clinical utility of the DASH remains unknown.
How to obtain the tool?	Visit the DASH website for more information: https://dash.iwh.on.ca/

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the DASH. While numerous studies have been conducted with other patient groups, this review specifically addresses the psychometric properties relevant to patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. At the time of publication there was 1 conference paper but no published studies specific to patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Floor/Ceiling Effects

No studies have reported on the floor/ceiling effects of the DASH in a sample of patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The DASH demonstrates no floor or ceiling effects in patients with shoulder and combined shoulder-upper limb problems (Bot et al., 2004).

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No studies have examined internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the DASH in a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., although studies conducted among patient groups with other upper limb conditions indicate excellent reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
(see: Atroshi et al., 2000; Bot et al., 2004; Veehof et al., 2002). However, this may indicate item redundancy (Beaton et al., 2005).

Test-retest:
No studies have examined test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the DASH in a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., although studies conducted among patient groups with other upper limb conditions indicate excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(see: Atroshi et al., 2000; Bot et al., 2004; Beaton et al., 2001).

Intra-rater:
No studies have examined intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the DASH in a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Inter-rater:
No studies have examined inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the DASH in a sample of patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Validity

Content:

The DASH was developed in two stages of item generation and item reduction. The first stage of item generation involved clinical expert input, review of 13 relevant outcome measurement scales and patient focus groups to identify possible items. The second stage of item reduction involved preliminary item review by three content experts, secondary review by a panel of 15 experts for content/face validityThe degree to which an assessment measures what it is supposed to measure.
and item importance, and subsequent pre-testing on 20 individuals with upper extremity difficulties. Further item reduction was conducted by psychometric and clinimetric analysis among patients with upper limb conditions, including (i) field-testing in a cross-sectional study of 407 patients with various upper limb problems, and (ii) importance- and difficulty- rating in a second sample of 76 patients. This resulted in the 30-item questionnaire (Hudak et al., 1996; Marx et al., 1999).

Lannin et al. (2010) examined the content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension.
of the DASH in a sample of 157 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Analysis of the original rating scale revealed a disordered structure; Rasch measurement modeling was used to transform ordinal ratings into a collapsed linear measure, which resulted in conformation to expectations of the model. The study also found that the hierarchy of the original 30 items is not appropriate for clinical use as there are few items suitable for the most disabled patient.

Franchignoni et al. (2010) investigated the dimensionality, rating scale diagnostics and model fit of the DASH (Italian version) on a sample of 238 patients with upper extremity disorders (excluding strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.). The authors noted that some items do not rely exclusively on upper limb function (e.g. item 9: Make a bed; item 20: manage transportation needs), and that items measure different ICF constructs (impairment, activity limitation and participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual's involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. restriction). The authors found that patients were not able to reliably use the 5-level rating scale. Factor analysis revealed 3 underlying constructs of: (i) manual functioning (items 1-5, 7-11, 16-18, 20, 21); (ii) shoulder range of motion (items 6, 12-15, 19); and (iii) symptoms and consequences (items 22-30). Two items (Tingling, Sexual ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
) showed misfit by Rash Analysis. While results from this study identify issues to consider when using the DASH, it is important to note that patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. were excluded from the sample population.

Criterion:

Concurrent:
No studies have reported on the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the DASH in a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Predictive:
No studies have reported on the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the DASH in a sample of patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Construct:

Convergent/Discriminant :
Lannin et al. (2010) conducted a comparison of the DASH with a self-report questionnaire of upper limb function and an observation upper limb movement assessment in 90 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The authors reported moderate correlations between manual ability and pain (statistical data not provided).

While no other studies have examined construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the DASH in a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., numerous studies conducted among patient groups with other upper limb conditions report adequate to excellent correlations with constructs of function and pain (see: Atroshi et al., 2000; Beaton et al., 2001; Bot et al., 2004; Kirkley et al., 1998; Schmitt & Di Fabio, 2004; SooHoo et al., 2002; Turchin et al., 1998).

Known Group:
No studies have examined known-group validityThe degree to which an assessment measures what it is supposed to measure.
of the DASH in a sample of patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., although studies have been conducted among patient groups with other upper limb conditions (see: Beaton et al., 2001).

Responsiveness

No studies have examined responsivenessThe ability of an instrument to detect clinically important change over time.
of the DASH in a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., although studies have been conducted among patient groups with other upper limb conditions (see: Beaton et al., 2001; Bot et al., 2004; MacDermid & Tottenham, 2004; Schmitt & Di Fabio, 2004).

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
& SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
:
No studies have examined responsivenessThe ability of an instrument to detect clinically important change over time.
of the DASH in a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., although studies have been conducted among patient groups with other upper limb conditions (see: Beaton et al., 2001).

References

• Atroshi, I., Gummesson, C., Andersson, B., Dahlgren, E. & Johansson, A. (2000). The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: reliability and validity of the Swedish version evaluated in 176 patients. Acta Orthopaedica Scandinavica, 71(6), 613-8.
• Beaton, D.E., Katz, J.N., Fossel, A.H., Wright, J.G., Tarasuk, V., & Bomardier, C. (2001). Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. Journal of Hand Therapy, 14, 128-46.
• Beaton, D.E., Wright, J.G., Katz, J.N., and the Upper Extremity Collaborative Group. (2005). Development of the QuickDASH: comparison of three item-reduction approaches. The Journal of Bone and Joint Surgery, 87-A(5), 1038-46.
• Bot, S.D.M., Terwee, C.B., van der Windt, D.A.W.M., Bouter, L.M., Dekker, J., & de Vet, H.C.W. (2004). Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature. Annals of the Rheumatic Diseases, 63, 335-41.
• Franchignoni, F., Biordano, A., Sartorio, F., Vercelli, S., Pascariello, B., & Ferriero, G. (2010). Suggestions for refinement of the Disabilities of the Arm, Shoulder and Hand outcome measure (DASH): a factor analysis and Rasch validation study. Archives of Physical Medicine and Rehabilitation, 91, 1370-7.
• Gummesson, C., Ward, M.M., & Atroshi, I. (2006). The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskeletal Disorders, 7(44). doi:10.1186/1471-2474-7-44.
• Hudak, P.L., Amadio, P.C., Bombardier, C., and the Upper Extremity Collaborative Group. (1996). Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Hand). American Journal of Industrial Medicine, 29, 602-8.
• Kirkley, A., Griffin, S., McLintock, H., & Ng, L. The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability: The Western Ontario Shoulder Instability Index (WOSI). The American Journal of Sports Medicine, 26(6), 764-72.
• Lannin, N. McCluskey, A. Cusick, A. Ashford, S. Ross, L. (2010) Measuring function in everyday life: enhancing the Disabilities of the Arm Shoulder Hand questionnaire for use post-stroke. World Federation of Occupational Therapy, Santiago, Chile, May.
• Lozano Calderon, S.A., Zurakowski, D., Davis, J.S., & Ring, D. (2010). Quantitative adjustment of the influence of depression on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Hand, 5, 49-55.
• MacDermid, J.C. & Tottenham, V. (2004). Responsiveness of the Disabilities of the Arm, Shoulder and Hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) in evaluating change after hand therapy. Journal of Hand Therapy, 17, 18-23.
• Marx, R.G., Bombardier, C., Hogg-Johnson, S., & Wright, J.G. (1999). Clinimetric and psychometric strategies for development of a health measurement scale. Journal of Clinical Epidemiology, 52(2) 105-11.
• Ring, D., Kadzielski, J., Fabien, L., Zurakowski, D., Malhotra, L.R., & Jupiter, J.B. (2006) Self-reported upper extremity health status correlates with depression. The Journal of Bone and Joint Surgery, 88-A(9), 1983-8).
• Schmitt, J.S. & Di Fabio, R. (2004). Reliable change and minimum important difference (MID) proportions facilitated group responsiveness comparisons using individual threshold criteria. Journal of Clinical Epidemiology, 57, 1008-18.
• SooHoo, N.F., McDonald, A.P., Seiler, J.G., & McGillivrary, G.R. (2002). Evaluation of construct validity of the DASH questionnaire by correlation to the SF-36. Journal of Hand Surgery, 27A, 537-41.
• Turchin, D.C., Beaton, D.E. & Richards, R.R. (1998). Validity of observer-based aggregate scoring systems as descriptors of elbow pain, function and disability. The Journal of Bone and Joint Surgery, 80A(2), 154-62.
• Veehof, M.M., Sleegers, E.J.A., van Veldhoven, N.H.M.J., Schuurman, A.H., & van Meeteren, N.L.U. (2002). Psychometric qualities of the Dutch language version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH-DLV). Journal of Hand Therapy, 15, 347-54.

See the measure

How to obtain the DASH?

You can obtain a copy of the DASH through https://dash.iwh.on.ca/