Finding a clinical assessment scale - Physical Medicine and Rehabilitation

Description:

The DASH is a self-assessment questionnaire developed in 1994 by representatives of the Institute for Work & Health (IWH) and the American Academy of Orthopaedic Surgeons (AAOS) (compilation then selection of questions from among over 500 questionnaires). It measures physical disability and symptoms for all disorders of the upper limbs in a heterogeneous population.

This questionnaire has been studied in the press in patients presenting neck pain, psoriatic arthritis, RA, post-operatively: shoulder prosthetic for omarthrosis, carpal tunnel syndrome, transposition of the ulnar nerve for cubital tunnel syndrome, carpometacarpal arthroplasty, neck surgery, and also post-proximal fracture of the humerus and Colles' fracture.

It comprises 30 questions. Among the 30 questions, 21 evaluate the difficulty in carrying out specific activities of day-to-day life. Among these 21 activities, eight are two-handed, five use only the dominant hand, and eight are carried out by both the dominant hand and the non-dominant hand. For the nine other questions, three concern social relations and six concern specific symptoms: pain (three questions), strength (one question), mobility (one question), and sleep (one question).
In addition to these 30 questions, there are two optional modules each of four questions, one on sport and music, and one on ability to work.

For each question, the patient must choose a value between 1 and 5 which corresponds to an increasing inability to accomplish certain activities during the last seven days. If the patient has not had the opportunity to practise some of these activities during the last seven days, they must circle the response that they feel would be most accurate if they had to undertake this task. It takes around 15 minutes to complete the test. It does not require any particular materials or staff training.

The DASH measures the ability according to the overall result. For example, a right-handed patient completely immobilised on the right side may respond that he has "no difficulty in turning a key in a lock" if he is quite adept at effectively using his left hand. The use of a third party assistant is prohibited.

However, if the patient uses an external material aid to carry out the tasks suggested (brace for example), he must respond according to his ability to carry out these tasks using the brace, specifying the nature of the aid used. The ability is assessed as a result, without taking account of the way in which it is achieved.

The values chosen for the 30 questions are added together, which gives a total score from 30 (no functional impediment) to 150 (maximum impediment). A golden rule: total score (TS) - 30 divided by 1.2 then makes it possible to reduce the score to a scale of 0 to 100, which is more intuitive to interpret. If there are more than four responses mission, the questionnaire is interpretable.

From the original questionnaire, a short version, the QuickDASH, has been developed, using a "concept-retention" approach. The QuickDASH contains 11 of the 30 items of the initial DASH. Another short version, the M2DASH (Manchester-modified), has been developed using more specific questions about the upper limb, and includes questions 1-4, 6, 13-17, 21-23, and 26-30 of the initial questionnaire.

One problem with the DASH is that a strong correlation has been observed between the pain levels, which could lead to high scores in a multiple-trauma population. No study has specifically evaluated the use of the DASH in this population.

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Psychometric properties:

General comment on reliability:

The validity of the DASH has been evaluated notably with regard to the Modified American Shoulder and Elbow Surgeons (M-ASES) [2], and the Shoulder Pain and Disability Index (SPADI) [4]. The DASH is well correlated with most items of the SF-36 [5, 9] and SF-12 [17]. It is also highly correlated with the Neck Disability Index (NDI) [22, 27], and quite well correlated with the Cervical Spine Outcome Questionnaire (CSOQ) and the VAS-pain [22].

Its accuracy is high [2, 4, 15, 23, 27], its sensitivity to change good [4, 17], and its internal consistency strong [15].

It is a valid instrument to assess the function of the upper limb and the inflammatory activity of the disease in patients suffering from psoriatic arthritis [3].
It is also a valid, accurate and usable instrument for patients presenting a Colles' fracture [6], with notably a correlation of the DASH scores with the ROM (range of motion).
It may be recommended as an instrument for routine clinical monitoring for RA patients [15] and post-operative patients following hand surgery [13].

The DASH can show the effectiveness of the treatment after surgery for subacromial impingement and carpal tunnel syndrome [7], comparably to the Boston Questionnaire [8]. However the carpal tunnel syndrome questionnaire (CTQ) [31] and the BQ are more sensitive to change than the DASH and the M2DASH [25]. With regard to cubital tunnel syndrome, the DASH is a valid measurement moderately sensitive to change after monitoring 3 months post-operative [26].

It can be used in patients having neck pain in addition to pain in the upper limbs, but is not recommended for use in isolated neck pain [17].

It can detect and differentiate changes (small and large) in the disability over time after surgery in patients having musculoskeletal problems of the upper limbs. A difference of 10 points in the average score can be considered as a minimum major change. [7]

The QuickDASH can be used instead of the DASH, with the same precision, in the evaluation of disorders of the upper limbs (similar psychometric qualities) [11], and notably in the case of associated neck pain [22]. Also, the correlations between the M2DASH and the DASH are highly significant [14].
It lacks data however concerning sensitivity to change of the DASH in neck pain [27] before being able to use this questionnaire in clinical practice.
A QuickDASH-9 was offered because, unlike the QuickDASH, it presented a unidimensional structure [16].

Two press reviews [10, 19] were undertaken with regard to the DASH. Notably they found that the psychometric qualities of the 3 scales are acceptable (ASES, DASH, and SPADI).

It is a reliable and valid instrument for measuring functional incapacity and studying the ergonomic risk factors in textile workers with complaints linked to upper limb pain [18].

The DASH was also studied in healthy athletes [21, 22]. There was a significant difference between their scores and those of the general population. However, its validity in these athletes was limited and the differences with the population could be minimised by a significant ceiling effect [22].

For the validation in French and Spanish, five stages were necessary: translation into French/Spanish, summary of the translations, back translation into English, review by a committee of experts, and testing of the pre-final version.
The translated versions presented all the psychometric qualities to validate its use in clinical practice or in studies [28, 29, 30, 31, 32, 33].
A French version of the QuickDASH was also validated and the strong correlation of the QuickDASH with the complete DASH suggests that this latter could be preferred as it is easier to use [34].

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