Disabilities of the Arm, Shoulder and Hand (DASH)

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.