Disabilities of the Arm, Shoulder and Hand (DASH)

Evidence Reviewed as of before: 19-06-2012
Author(s): Annabel McDermott, OT
Editor(s): Nicol Korner-Bitensky, PhD OT
Expert Reviewer: Dr. Natasha Lannin (Associate Professor, OT)
Content consistency: Gabriel Plumier

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 validity and responsiveness 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 activities:

  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 activities that require little effort (e.g. card playing, knitting)
  18. Recreational activities that require taking some force or impact through the arm, shoulder or hand (e.g. golf, hammering, tennis)
  19. Recreational activities that require you to move the arm freely (Frisbee, badminton)
  20. Managing transportation needs (getting from one place to another0
  21. Sexual activities
  22. Extent to which arm, shoulder or hand problems interfered with normal social activities with family, friends, neighbours or groups
  23. Extent to which arm, shoulder or hand problems limited work or other regular daily activities

Severity of the following symptoms:

  1. Arm, shoulder or hand pain
  2. Arm, shoulder or hand pain when performing activities
  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 scale 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 correlation between the DASH and measures of depression (Center for Epidemiologic Studies – 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 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 correlation between DASH and depression-adjusted DASH scores, indicating no notable benefit to adjusting DASH scores for depression. Given the high incidence of depression among patients with stroke, consideration of the correlation between disability and 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 stroke 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 activities 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 activities with family, friends, neighbours or groups
  8. Extent to which arm, shoulder or hand problems limited work or other regular daily activities
  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 reliability, validity and responsiveness to the DASH and may demonstrate better precision in detecting different degrees of disability than the DASH. Although there is a high 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 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 screening 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
Reliability

Internal consistency:

No studies have reported on the internal consistency of the DASH among patients with stroke.

Intra-rater:

No studies have reported on the intra-rater reliability of the DASH among patients with stroke.

Inter-rater:

No studies have reported on the inter-rater reliability of the DASH among patients with stroke.

Test-retest:

No studies have reported on the test-retest reliability of the DASH among patients with stroke.

Validity

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 validity of the DASH in a sample of patients with stroke 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 validity of the DASH among patients with stroke.

Predictive:

No studies have reported on the predictive validity of the DASH among patients with stroke.

Construct:

Convergent/Discriminant:

One study reported moderate correlations between manual ability and pain.

Known Groups:

No studies have reported on the known-groups validity of the DASH among patients with stroke.

Floor/Ceiling Effects No studies have reported on the floor/ceiling effects of the DASH among patients with stroke.
Does the tool detect change in patients? No studies have reported on the responsiveness among patients with stroke.
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 stroke 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: http://www.dash.iwh.on.ca/home

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 stroke. At the time of publication there was 1 conference paper but no published studies specific to patients with stroke.

Floor/Ceiling Effects

No studies have reported on the floor/ceiling effects of the DASH in a sample of patients with stroke. The DASH demonstrates no floor or ceiling effects in patients with shoulder and combined shoulder-upper limb problems (Bot et al., 2004).

Reliability

Internal consistency:
No studies have examined internal consistency of the DASH in a sample of patients with stroke, although studies conducted among patient groups with other upper limb conditions indicate excellent reliability (see: Atroshi et al., 2000; Bot et al., 2004; Veehof et al., 2002). However, this may indicate item redundancy (Beaton et al., 2005).

Intra-rater:
No studies have examined intra-rater reliability of the DASH in a sample of patients with stroke.

Inter-rater:
No studies have examined inter-rater reliability of the DASH in a sample of patients with stroke.

Test-retest:
No studies have examined test-retest reliability of the DASH in a sample of patients with stroke, although studies conducted among patient groups with other upper limb conditions indicate excellent test-retest reliability (see: Atroshi et al., 2000; Bot et al., 2004; Beaton et al., 2001).

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 validity 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 validity of the DASH in a sample of 157 patients with stroke. 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 stroke). 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 participation 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 Activities) 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 stroke were excluded from the sample population.

Criterion:

Concurrent:
No studies have reported on the concurrent validity of the DASH in a sample of patients with stroke.

Predictive:
No studies have reported on the predictive validity of the DASH in a sample of patients with stroke.

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 stroke. The authors reported moderate correlations between manual ability and pain (statistical data not provided).

While no other studies have examined construct validity of the DASH in a sample of patients with stroke, 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 validity of the DASH in a sample of patients with stroke, although studies have been conducted among patient groups with other upper limb conditions (see: Beaton et al., 2001).

Responsiveness

No studies have examined responsiveness of the DASH in a sample of patients with stroke, 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).

Sensitivity & Specificity:
No studies have examined responsiveness of the DASH in a sample of patients with stroke, 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 www.dash.iwh.on.ca

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