Disabilities of the Arm, Shoulder and Hand (DASH)

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.

Spoiler title

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