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
Dorcas E. Beaton, BScOT, MSc, PhD
Institute for Workand Health
Toronto, Ontario, Canada;
Department of Occupational Therapy,
Graduate Department of Rehabilitation .
Sciences, and Clinical Epidemiology and
Health Care Research Program
University of Toronto;
St. Michael's Hospital, Toronto
Jeffrey N. Katz, MD, MS
Institute for Workand Health, Toronto;
Graduate Department of Rehabilitation Sciences
University of Toronto;
Brigham and Women's Hospital and
Harvard Medical School
Boston, Massachusetts
Anne H. Fossel
Brigham and Women's Hospital
Boston, Massachusetts
James G. Wright, MD, FRCSC, MPH
R. B. SalterChair in Surgical Research,
Department of Surgery, University of Toronto;
Graduate Department of Rehabilitation Sciences,
Clinical Epidemiology and Health Care Research
Program, and Department of Public Health
Sciences
University of Toronto;
The Hospital for Sick Children, Toronto
Valerie Tarasuk, PhD
Department of Nutritional Sciences
University of Toronto
This work was supported by research grants from the American
Society for Surgery of the Hand, Rosemont, Illinois, and the
Institute for Work and Health, Toronto, Ontario, Canada; by a
PhD fellowship in health research from the Medical Research
Council of Canada (Dr. Beaton); by a scientist award from the
Medical Research Council of Canada (Dr. Wright); and by grant
128 JOURNAL OF HAND THERAPY
Claire Bombardier, MD, FRCP
Institute for Workand Health, Toronto;
Graduate Department of Rehabilitation Sciences,
Clinical Epidemiology and Health Care Research
Program, Department of Medicine, and Department
of PublicHealth Sciences, University of Toronto;
The University Health Network
Toronto General Hospital;
Mt. Sinai Hospital, Toronto
ABSTRACT: The Disabilities of the Ann, Shoulder and Hand
(DASH) outcome measure was developed to evaluate disability and
symptoms in single or multiple disorders of the upper limb at one
point or at many points in time. Purpose: The purpose of this study
was to evaluate the reliability, validity, and responsiveness of the
DASH in a group of diverse patients and to compare the results
with those obtained with joint-specific measures. Methods: Two
hundred patients with either wrist/hand or shoulder problems
were evaluated by use of questionnaires before treatment, and 172
(86%) were re-evaluated 12 weeks after treatment. Eighty-six
patients also completed a test-retest questionnaire three to five days
after the initial (baseline) evaluation. The questionnaire package
included the DASH, the Brigham (carpal tunnel) questionnaire, the
SPADI (Shoulder Pain and Disability Index), and other markers of
pain and function. Correlations or t-tests between the DASH and
the other measures were used to assess construct validity.
Test-retest reliability was assessed using the intraclass correlation
coefficient and other summary statistics. Responsiveness was
described using standardized response means, receiver operating
characteristics curves, and correlations between change in DASH
score and change in scores of other measures. Standard response
means were used to compare DASH responsiveness with that of the
Brigham questionnaire and the SPADI in each region. Results: The
DASH was found to correlate with other measures (r> 0.69) and to
discriminate well, for example, between patients who were working
and those who were not (p < 0.0001). Test-retest reliability
(ICC=0.96) exceeded guidelines. The responsiveness of the DASH
(to self-rated or expected change) was comparable with or better
than that of the joint-specific measures in the whole group and in
each region. Conclusions: Evidence was provided of the validity,
test-retest reliability, and responsiveness of the DASH. This study
also demonstrated that the DASH had validity and responsiveness
in both proximal and distal disorders, confirming its usefulness
across the whole extremity.
J HAND THER. 2001;14:128-146.
AR36308 from the U'S. National Institutes of Health and the u.s.
National Arthritis Foundation (Dr. Katz).
Address correspondence and reprint requests to Dorcas Beaton,
BScOT,MSc, PhD, Institute for Work and Health, 250 Bloor Street
East, Suite 702, Toronto, Ontario, Canada M4W 1E6; e-mail:
<dbeaton@iwh.on.ca>.
 The measurement of disabilityv ' or capacity to
function" is critical to a comprehensive assessment of
outcome following an injury in the upper limb. The
fluid motion of a swimmer, artist, or musician attests
to the coordinated kinetic chain along the extremity
which allows for such expression and function.Y'
However, measuring disability in patients with
upper-limb disorders poses practical challenges. For
example, distinct questionnaires have been devel-
oped for the different regions of the uPfer limb7~11
and for various disorders in the limb.12-1 Given that
many patients could have multiple disorders or mul-
tiple affected regions, the choice between available
measures is difficult. The Disabilities of the Arm,
Shoulder and Hand outcome measure (the DASH)
provides one possible solution. It is a questionnaire
designed to be used for single or multiple disorders in
the upper limb, providing the possibility of a single
questionnaire for measuring disability for any upper-
limb region. 5,15,16 The intent is that the DASH be used
no matter what region or regions are affected.
The development of the DASH has been docu-
mented elsewhere. I5-17 The DASH is a 30-item ques-
tionnaire that evaluates symptoms and physical
function (at the level of disabilityl,3,18), with a five-
response option for each item. Scoring is done by
summing up the circled responses and subtracting
30. (Subtracting 30 anchors the score with a base of 0,
a correction required because the response scale is 1
to 5 and needs to be changed to a 0 to 4 equivalent).
This figure is then divided by 1.2 to get a DASH func-
tion/symptom score out of a possible 100.
A higher score on the DASH reflects greater dis-
ability. Missing responses to items (up to three items,
or 10% of items) are replaced by the mean value of
the responses to the other items before summing. If
responses to more than three items are missing, the
overall score cannot be calculated.P
Preliminary work on the validity (against con-
structs of function and pain) and reliability (alpha,
0.9615; test-retest reliability, 0.9219) has been carried
out directly by those involved in the develop-
mentl5-17 as well as indirectly by others who used the
DASH for comparison with another instrument. 14,20
Kirkley et aL14 and MacDermid et aL20 also demon-
strated that the DASH was responsive, although
slightly less so, in comparison with more joint- or dis-
order-specific measures-specifically, a shoulder
instability and a wrist-specific instrument in these
studies respectively.
These studies provided initial evidence of the
validity and reliability of the DASH scores; however,
additional work was needed to compare the DASH
in patients with disorders in different upper-limb
regions. Of particular interest was how the DASH
would do in evaluating change over time (its intend-
ed role) in patients with different affected parts of the
extremity, a role that requires evidence of construct
validity, test-retest reliability and responsive-
ness. 21-25 Of the articles mentioned above that used
the DASH, only three collected data over time for the
study,14,19,20 none focused on the DASH per se, and
none provided information on all three attributes.
The purpose of this study was to evaluate the valid-
ity, test-retest reliability, and responsiveness to
change of the DASH in a longitudinal study of
patients with various upper-limb disorders.
METHODS
A convenience sample of patients waiting for treat-
ment of upper-limb conditions at one of two teaching
centers (St. Michael's Hospital in Toronto and
Brigham and Women's Hospital in Boston) were
invited to participate in this prospective cohort
study. The study did not affect their care but rather
noted their progress over a three-month period by
taking measures (through questionnaires only)
before and after treatment.
Four groups of patients, two with proximal disor-
ders and two with distal disorders, were targeted.
The patients with proximal disorders included those
with glenohumeral arthritis who were undergoing
joint replacement and those with soft tissue disorders
around the shoulder (predominantly rotator cuff ten-
dinitis). Patients with distal disorders included those
undergoing carpal tunnel release and those receiving
treatment for a tendon disorder in the wrist or hand
(predominantly trigger finger and tendinitis). Acute
injuries such as tendon lacerations or fractures were
not included, because pre-treatment measures of dis-
ability cannot be obtained in these conditions.
No guidelines were available for calculating sam-
ple sizes for studies of responsiveness. A traditional
paired sample calculation (alpha at 0.025, a
Bonferroni correction to allow for multiple compar-
isons." and beta at 0.10) was used. 27
The amount of change we wanted to be able to
detect was calculated using data from a worksite
study and was defined as the difference in improve-
ment on the DASH scores between those who said
they were much better and those who said they were
somewhat better between testings one year apart. 28,29
The former group had change scores of 5.79 out of
100 (SD 11.2) on average, and the latter had change
scores of 2.42 out of 100 (SD 12.3). The difference
between them was 3.37 out of 100. The average
change in those who said they had not changed
between testings was 0.89 out of 100 (SD 9.9). The SD
in this group was used as the variance in the sample
size calculation, as suggested by Guyatt et aL30 and
Rossner."
A sample of 113 patients was required. A 20% cor-
rection was added to allow for missing or unusable
questionnaires, which raised the requirement to 142
patients. (The target of 113 patients was assumed to
April-June 200 I 129
equal 80% of the data collected.) We anticipated that up
to 20% of participants would not complete the follow-
up package; hence, recruitment was targeted for 178
patients. We continued recruitment until it was appar-
ent that we would have follow at least this number and
that it represented at least 80% of the baseline sample.
Patients at the St. Michael's Hospital site were
approached in person by study personnel (either at a
surgeon's clinic or in a pre-admission clinic). The
study was explained to them, and they were asked to
sign a consent form if they wished to participate. At
that time they were given the baseline package to
complete and return as well as a second package to
be completed three to five days later (depending on
the date of surgery). Two follow-up packages were
mailed out to the subjects with stamped return
envelopes. This was done 4 and 12 weeks after treat-
ment. (Only 12-week data are presented in this
paper.) Up to two reminder packages and phone calls
were made to encourage response.
In Boston, study personnel identified patients by
reviewing ICD-9-CM diagnostic codes in billing data
and looking for patients receiving or awaiting surgical
or nonsurgical care for the target disorders. These
potential subjects were sent detailed letters explaining
the study and inviting them to participate. The base-
line questionnaire package and a stamped return
envelope were also included. Participation (returning
the baseline questionnaire package) was considered
consent. Subjects from Boston were sent their second
package by mail at 12 weeks. Again, phone calls and
reminder packages (up to two) were sent as necessary.
The study was approved by the Research Ethics
Board at both sites.
MEASURES AND ANALYSIS
Each completed questionnaire package was
checked by research staff for such things as missing
items and duplicate responses and was then entered
into a customized database at each site. These data
were converted into SAS (version 6.12) data sets (SAS
Statistical Analysis Systems, Cary, North Carolina)
and merged. All analysis was done in SAS.
Sample Description
Baseline demographics for the whole cohort were
analyzed descriptively. This was repeated separately
for subjects from each of the two data collection sites.
The variables described included age, gender, educa-
tion, and clinical variables (comorbidity, pain med-
ication use, duration of symptoms, etc.). The SF-36
generic health status measure32,33 was also used to
describe baseline overall health in the cohort. Means
and medians for each dimension of the SF- 36 were
calculated for the entire cohort and plotted against
mean values for the general Ll.S. population.
130 JOURNAL OF HAND THERAPY
Construct Validity
Several different comparisons were done, using
recommended methods, to evaluate the construct
validity of the DASH scores. 25,34
We hypothesized that the DASH scores would be
sensitive to the range of disability in our sample. This
was verified by looking at the distributions of base-
line scores (whole sample, proximal, distal, surgical,
nonsurgical) and specifically looking for floor or ceil-
ing effects (patients with scores at either extreme of
the scale), which would indicate a lack of sensitivity
to the disability experience in this sample. Floor and
ceiling effects would also lead to difficulties in trying
to measure change (for instance, if everyone scores at
the maximum score--a ceiling effect-there is no
place to move to on the scale if they improve).35
We also felt that the DASH scores should be lower
(indicating less disability) in the following groups:
those working full duty rather than not and those
able to cope and do what they want rather than not.
These contrasts were tested with an unpaired
Student's t-test, at a 0.05 level of error.
We posited that the DASH should also correlate at
least moderately (Pearson correlations greater than
0.5) with visual analog scales of function, pain, and
ability to work as well as with established joint-spe-
cific measures, specifically the Shoulder Pain and
Disability Index (SPADD for patients with shoulder
conditions7,36,37 and the Brigham questionnaire (the
Brigham) 12,38 for patients with wrist and hand condi-
tions).
Furthermore, if the joint-specific measures are
indeed specific to a particular joint, we should see
lower correlations between the DASH and the
Brigham in the patients with shoulder conditions as
well as between the DASH and the SPADI in the
patients with wrist conditions. The disability or func-
tion scores of the SPADI and the Brigham were the
focus of this analysis.
Test-Retest Reliability
Test-retest reliability was analyzed using data
from patients who had completed two measures
before treatment began (three to five days apart) and
said that their ann problem had not changed (in
response to the question, "How is your problem now
compared to before your treatment/surgery?")
.Mean change scores and associated paired t statistics
(and p values) were calculated. Correlation coeffi-
cients were obtained using both the Pearson method
(parametric, for normally distributed data) and the
Spearman method (non-parametric, using ranks).
These correlations indicate whether scores for a given
patient are high at baseline and also high at follow-
up but not whether the scores are identical.
Intraclass correlation coefficients (ICCs) provide an
estimate of how closely the numeric scores for each
patient were to each other (called concordance,and
are therefore considered a stronger statistic for
describing reliability,z,39,4o Specifically, we used a
Shrout and Fleiss (2,1) model derived from a two-
way analysis of variance.t" By adopting this particu-
lar model, we are saying that the testing framework
in this particular study (three to five days apart, pre-
treatment) is assumed to be only one of many possi-
ble ways the test-retest reliability could have been
assessed. We considered a coefficient between 0.90
and 0.95 a minimum standard for reliability, based
on the guidelines of Lohr et al. 25 and others. 34,4l for
the ability to interpret questionnaire scores in indi-
vidual patients.
The final estimate of reliability, the minimally
detectable change (MOC),42-46 was calculated using
the test-retest reliability coefficient to estimate the
standard error of measurement (SEM) for the differ-
ence score.t' The SEM was therefore the SO at base-
line (a base) times the square root of (1- RxX>, where R xx
is the test-retest reliability.t! Christensen and
Mendoza'f and others4l,47 suggest multiplying the
(1-R xX> by 2, to adjust for the fact that when looking
at a change score two samples are being used (time-I
and time-2), each with measurement error. The SO is
therefore increased by this factor to account for this.
From this calculation of the SEM, it is possible to
describe the amount of change that would need to be
observed on the questionnaire to exceed this meas-
urement error. In health measurement, the terms
"minimally detectable change,,45,48 and "smallest
detectable difference or change,,47 have been used for
this change score. It is calculated by multiplying the
SEM by the appropriate z value (depending on the
level of confidence desired). Thus, for a minimal
detectable change at the 95% confidence level, the
formula would be
The subscript 95 is used with the label because it is
possible to calculate this change score at different lev-
els, including 90%48 and 67%.46 The MOC95 yields a
threshold-a minimum change score-that allows
you to be 95% confident that when you observe a
change score that is greater than this value, it is likely
to indicate a real change in your patient, rather than
measurement error (for that instrument in that popu-
lation) alone. The MOC provides a unique opportuni-
ty to translate the test-retest reliability coefficient
(ICC) into units of change in the instrument.
It should be noted that the ways others calculate
these values vary. In early work, Jacobson et a1. 43 did
not double the error term; however, Jacobson has
since chan§ed this position and adopted the adjusted
formula.t'" 1 Wyrwich et al., in their work on bounds
of relevant change,46,52 do not use the adjustment-to-
the-error term and replace the test-retest reliability
coefficient with the Cronbach alpha coefficient. The
use of the alpha moves away from longitudinal sta-
bility as the source of the variance and favors instead
an instrument with high correlations between items,
a cross-sectional strength." Wyrwich et al. argue,
and we agree, that in cases of very high sample sizes,
the Cronbach alpha and test-retest coefficients will
be almost the same34,46,52; however, in our experience
in clinical research, such large samples (N - 300)34
samples are rarely found. Test-retest coefficients
derived from similar patients are preferable. Caution
should be used to avoid confusing the Wyrwich co-
efficient with what appear to be similar coefficients
under the rubric of minimal detectable change or reli-
ability change indexes.
Responsiveness to Change
The ability to detect change when it has
occurred,53,54 or responsiveness, is often incorrectly
felt to be a fixed property of an instrument (e.g., the
XXX questionnaire is "responsive"). However, it is
more like construct validity, in which we are validat-
ing the application of the instrument in a specific test
situation, not the instrument in and of itself.
Evaluation of responsiveness requires that some sort
of change has occurred (and that it can be verified in
some way), and then the questionnaire's scores are
tested against that change. It is possible that a given
questionnaire could be responsive or sensitive to a
particular type of change but not to another type. 55,56
Responsiveness needs to be described in relation to
the relevant type of change.
In our study, we looked at three types of change
known to have occurred between baseline and 12
weeks after the beginning of treatment. First, we
assumed that patients would likely begin to show
improvement with each of the treatments in the study
(i.e., total shoulder replacement, carpal tunnel release),
and therefore we compared pre-treatment and 12-
week post-treatment scores in the whole group. We
recognize that this does not reflect full recovery, but
patients are likely to have had small improvements
from their pre-treatment states by this time.
Second, we looked at patients who said that their
upper-limb problem was better. We determined this
by their response to the Tl-point scale asking,
"Compared to before your treatment/surgery, how
much has your arm (either shoulder or wrist/hand)
problem changed?" Those indicating more than 6 on
the scale (where 5 indicates no change and 10 indi-
cates much better) were considered to have
improved. Different cut-off points could have been
used; however, we chose this point on the basis of an
a priori consensus of four of the authors (O.B., C.B.,
J.G.W., and J.N.K.). Similarly, an indication of
improvement of more than 6 in ability to function in
April-June 200 I 131
 TABLE 1. Sociodemographic Data for the daily activities was used as an external indication
Study Participants that change had occurred, and responsiveness analy-
Whole
Boston Toronto
sis was carried out on that subsample of patients
Cohort who indicated more than 6 of 10 on the scale.
(n=91) (n=109)
(n =200) In all cases, responsiveness was summarized using
Follow-up rate-no. (%) the following statistics-change scores (the mathe-
completing baseline and 172 78 94 matical difference between baseline and follow-up
12-wk follow-up (86%) (86%) (86%)
scores), effect size57 (mean change divided by the SD
Age (mean 53.6 54.4 52.9 of baseline scores) and the standardized response
Gender:
mean58--{jO (mean change divided by the SD of change
scores, or SRM). A comparison was then carried out
Male 86 29 57 contrasting the responsiveness (using the SRM) of the
Female 113 62 51 DASH, the Brigham, and the SPADI in each of the
subcohorts-patients with shoulder conditions and
Marital status:
patients with wrist or hand conditions. We thus eval-
Married/living 146 65 81 uated the responsiveness of a shoulder questionnaire
Divorced/separated 17 8 9 to improvements in wrist patients and vice versa. It
was hypothesized that the responsiveness of the
Widowed 14 7 7
DASH should be comparable with that of the joint-
Single 21 11 10 specific measures but that the highest responsiveness
Schooling: would be found for the joint-specific measures for
patients in whom that joint was involved.
Less than grade 8 10 1 9
Responsiveness was also described by correlating
Some high school 28 3 25 change scores on the DASH with changes in pain
(14%) (3%) (23%) intensity, function, and severity of the problem. Two
High school 31 11 20 approaches were used to measure these attributes.
First, numeric rating scales were used to gather these
Some college or university 29 14 15
ratings at each testing time (we called these "status
Graduated from college or measures"), and the differences between the status
university 98 61 37 measures at 12 weeks and at baseline (we called these
(50%) (67%) (34%)
"differences in status measures") were correlated with
Work status: the difference in DASH scores. Second, we also asked
Full time 78 39 39 patients (at 12 weeks) to rate the amount these same
attributes had changed since baseline (pre-treatment).
Part time 20 14 6
We called this "a transition approach." It would be
Disabled because of DE 23 2 21 hypothesized that both approaches should lead to at
(12%) (2%) (19%) least moderate correlations with changes in the DASH
Disabledfor other reason 8 3 5 scores. Slightly lower correlations were expected
because the comparison measures are made up of only
Homemaker 15 7 8
one or two items and hence are prone to more meas-
Retired 49 22 27 urement error, which would lower the correlation
Student 2 2 0 coefficient (attenuation of correlatiorr'"). The correla-
tions are also reduced because the change scores are
Worker's compensation:
derived from two samples (pre- and post-treatment),
No, not on worker's which also adds to the error in the measure (as dis-
compensation 156 82 74 cussed above) and causes further attenuation of the
Yes, but not yet 14 2 12 correlation. We therefore considered an r value of
about 0.4 indicative of a moderate correlation.
Yes, receiving it 14 0 14
We also constructed receiver operating characteris-
Yes, but no longer 9 4 5 tics (ROC) curves, as described by others.61,62 These
Lawyer for DE? curves demonstrate how accurately different change
(% yes) 13 6 7 scores on the questionnaire distinguish those who are
(6%) (7%) (6%) better from those who are not (as defined by some
NOTE: The first column represents the whole cohort, the second other criterion). In our study we used an affirmative
and third that portion of the cohort coming from each of the sites. answer to the question "Can you cope with your
The differences between the Boston and Toronto cohorts are problem and do what you would like to do?" at fol-
noted, although they are not likely to affect analysis of the ques-
tionnaires in the whole cohort. Analysis across study sites was not low-up, given an inability to cope at baseline, as the
done. criterion of improvement. We selected this question

\32 JOURNAL OF HAND THERAPY

on the basis of a qualitative study in which this was TABLE 2. Clinical Characteristics of the
described as a threshold type of indicator of being Study Participants
"better.,,63 This seemed to be a reasonable marker for Whole Sample Boston Toronto
Characteristic
change; however, it is not a "gold standard," and (n=200) (n=91) (n=109)
other markers could also have been used. Region affected:
Changes in DASH scores of -1,-5, -7, -10, -IS, and
Shoulder 138 61 77
-20 were considered" and were compared with the
external marker to see how well each change score cor- Wrist/hand 62 30 32
rectly corresponds to the external marker. The true- Duration of symptoms
positive rate (the percentage of people who had a (mean weeks): 193 178 206
change score of at least that amount and were also (SD 374)
now able to cope) and the false-positive rate (l minus Medication use:
specificity, or the percentage of people who had a Aspirin, NSAID 117 60 57
change score of at least that amount but had not shift- Tylenol (OTC) 90 39 51
ed from being unable to being able to cope) were cal- Narcotics 59 20 39
culated and plotted on a graph-a ROC curve.66 The
Other 45 20 25
area under the curve represents the responsiveness;
the larger the area, the more responsive the instru- Not taking medication 17 9 8
ment, because the different change scores accurately Comorbidity:
discriminate between improved and non-improved Hypertension 52 23 29
patients as defined by our external marker. In a ROC
Asthma 23 12 11
curve for one instrument, the point highest to the
upper left might be considered the change score most Diabetes 13 4 9
able to discriminate between those who have shifted Ulcers 29 10 19
to coping with their condition and those who have not. Depression 51 21 30
(26%) (23%) (27%)
RESULTS Cancer 16 8 8

Sample Description Arthritis 83 41 42

Low back pain 124 59 65
Two hundred patients were enrolled and complet- (62%) (65%) (60%)
ed the baseline portion of this study. One hundred No. of comorbid conditions:
and seventy-two completed the 12-week follow-up None 29 11 18
questionnaire (86% follow-up rate). The description
One 48 23 25
of the samples differed between sampling sites.
However, because we are making within-person, and Two 57 25 32
not between-site, analyses, the differences should not Three 29 18 11
affect the results. Four 25 9 16
The description of the sample is shown in Table 1.
Five or more 12 5 7
The first column reflects the findings in the whole
cohort, the second and third columns the Boston
(n = 91) and Toronto (n = 109) subsamples, respective-
ly. The mean age and marital status were similar The level of education of patients differed between
across sites. The average age was 42 years, and the sites. In Boston 67% had graduated from university
majority of people were married. The split between or college, whereas in Toronto only 34% had done so.
men and women was fairly even in the whole sam- In contrast, a larger proportion of the Toronto sample
ple, but most of the male patients came from Toronto. indicated that their highest educational level was
"completed some high school" (25%) than the Boston
sample (3%). Level of employment differed, with
*The reasons these change scores were selected for the cut-offs are more people being off work due to their upper- limb
as follows: 1 is closest to the smallest change detectable on the
DASH (0.83).63 A change of 5 is equivalent to one standard error problem in Toronto (19%) than in Boston (2%).
of measurement, which Wyrwich et aL46 suggest is close to a min- Likewise, the Toronto group had a higher proportion
imally clinically important difference; the cut-off suggested by of persons on worker's compensation.
Redelmeier and Lorig64 is 7 (or 7% change). A cut-off of 10 is
selected for convenience only. A cut-off of 15 corresponds to the Table 2 summarizes some of the clinical findings for
minimally detectable change derived from the work of Turchin et the whole cohort as well as for each site. The majority
al. 19 but also corresponds to the suggestion of Redelmeier et a1.65 of the patients with shoulder conditions were from
that the criterion for an important change is 0.5 points per item in
a questionnaire (therefore, 30 x 0.5). Finally, we selected a cut-off of Toronto, especially those with osteoarthritis (undergo-
20 to represent an extreme change score. ing shoulder replacement). The mean duration of

April-June 200 I 133

100 , - - - -- -...- - - - - - -- - . - - - , - - --,
FIGURE 1. SF-36 health status: Results for entire cohort
compared with U.S. general population data (solid
squares),32 expressed as baseline mean scores (gray line)
and median scores (solid triangles) in the eight SF-36
dimensions, and as two component scores. The eight SF-
60 36 dimensions are physical function (PF), social function
(SF), role-physical (RP), role-emotional (RE), mental
health (MH), vitality (VT), bodily pain (BP), and general
40 health perceptions (GH); the component scores are the
physical component score (PCS) and the mental compo-
20 . . - _. _.. . . - _. - _. -_ . - _. - _. _. -- - _. - _. _. - _. nent score (MCS). A score of 100 indicates good health.
Population norms for the United States were done on SF-
36-US with a 4-week window. The study data were gath-
o '-- J
ered on the Canadian version of SF-36 Acute.
PF SF RP RE MH VT BP GH PCS MCS

Number
35
whole cohort mean=43.9
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . s.dev'n=22.9 -
30
__ _ _ _ _ . median=44.6 _

25

20

15

10

o
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
" ,,<::I '),<::1 ~<::I ",,<::I ,,<::I '0<::1 ~<::I '0<::1 0,<::1 -c
DASH Score
shoulder patients wrisUhand patients
40 , . - - - - - - - - - - -- - - - - - - -, 40 . - -- - - - - - --'--- - - - - - - --,
mean =48.4 mean=34 .2
s.dev'n=21.2 s.dev'n=23.69
_ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ medlan=31 .25
30 - - - - - - - - - - - - - - - - - - - - - - - - - - median=50 .0 - 30

20 - ---- - - - - - - - - - - - - - - - - - - - - - 20 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

o
~ .!' ,,(:/,,0, -5'~ 4f} tl'o, <,ff<f> ~ '\(:/~ .a!' cfirf' ,,<f' ~ -?o, ,,(:/~ -5'~ -¥"? ...,:l <,ff<f> ~ '\(:/'\0, .a!' cfirf' ,,<f'
DASH Score DASH Score

FIGURE 2. Baseline distribution of DASH scores (out of 100) for the entire sample (top) and for the subsamples defined by the loca-
tion of patients' problems-shoulder (bottom left) or wrist/hand, (bottom right). A DASH score of 100 indicates greater disability.

TABLE 3. Construct Validity; Pearson/Spearman Correlations Between the DASH and

Other Measures of Upper Extremity Function
Whole Cohort (n=200) Shoulder (n = 138) Wrist/Hand (n = 62)
Overall rating of problem 0.71 /0.69 0.69/0.68 0.68/0.74
Pain severity 0.72 /0.72 0.73/0.71 0.67/0.71
Ability to function 0.79/0.79 0.84/0.85 0.75/0.78
Ability to work 0.76/0.77 0.76/0.76 0.69/0.74
SPADIpain 0.82/0.82 0.79/0.76 0.84/0.85
SPADI function 0.88/0.87 0.85/0.83 0.92/0.88
Brigham symptoms 0.71 /0.70 0.73/0.71 0.70/0.73
Brigham function 0.89/0.89 0.90/0.90 0.92/0.92

134 JOURNAL OF HAND THERAPY

symptoms was 193 weeks, more than three years, and
both sites offered secondary or tertiary levels of care.
The majority of the sample were taking some sort of
medication to manage symptoms preoperatively,
including 59 patients (of the 200 total) who stated that
they were taking narcotics for their pain. Of interest is
the high proportion of patients with histories of
depression (23% in Boston and 27% in Toronto) and
low back pain (65% in Boston and 60% in Toronto).
The general health of the cohort is shown in Figure 1,
where the mean and median scores in each dimension
of the SF-36health status measure are plotted with data
from the general population ofthe United States.
Construct Validity
The distribution of the baseline scores on the
DASH appear to be normally distributed (Figure 2),
with mean of 43.9 and median of 44.6. Only one
patient was at the "ceiling" (with a score of 0), indi-
cating perfect health, and no one was at the floor
(with a score of 100, indicating maximum disability
on the scale). The distribution for the patients with
shoulder conditions and patients with wrist or hand
conditions, shown in the same figure, demonstrates
the less severe disability in the patients with wrist
and hand conditions, described by the DASH scores.
Discriminative validity was confirmed. Those cur-
rently working with their upper limb condition and
able to continue doing so had significantly lower dis-
ability than those who were not able to work (26.8 vs.
50.7, t=-7.51, p<O.OOOl). (This analysis contrasted
only these two subgroups and did not analyze the
responses from those who were retired or not work-
ing for reasons other than their upper limb condi-
tion.) Statistically significant differences in DASH
scores were also found between those who were able
to do all they want to do as opposed to those who
were not able to do so (23.6 vs. 47.1, t = -5.81,
P< 0.0001). Similar discrimination was found within
the patients with shoulder conditions and those with
wrist or hand conditions when these groups were
analyzed separately. Thus, the difference was in the
anticipated direction (patients who were unable to do
what they wanted and those who were unable to
work had more disability and higher DASH scores),
and the difference was statistically significant.
Convergent construct validity of the DASH was
demonstrated by finding correlations in the expected
direction and of the expected magnitude with other
measures of upper limb function and symptoms.
Table 3 summarizes the results. In the whole cohort,
all correlations exceeded 0.70 (Pearson). Correlations
were highest with the measure of function as well as
with the function scores on the Brigham and the
SPAD!. Correlations between the DASH and these
joint-specific instruments were found even in the
opposite joint.
Test-Retest Reliability
Fifty-six of the 86 people completing the test-retest
reliability package (three to five days after baseline)
indicated that they had no change in their problem
(no change ± 1 response category on an ll-point tran-
sitional scale). The mean change score in this group
was -0.15 (median, 0), with an SO of 6.08. The differ-
ence was not significant (paired t statistic, -0.176;
p value, 0.86). The correlation between baseline and
retest was 0.96 (Pearson correlation) and 0.95
(Spearman ranked correlation). The ICC(2,1) on this
sample (n = 56) was 0.96 (95% confidence interval,
0.93-0.98) for the DASH, indicating excellent agree-
ment. 25,34,41,67 The SEM is 4.6 DASH points, which led
to a minimal detectable change (MDC 95) of 12.75 (SO
at baseline, 23.02) on a 100-point scale. A 90% MDC
(MDC 90 ) would be 10.7 of 100 DASH points.
Responsiveness
The DASH questionnaire was able to demonstrate
change in all situations in which change was pre-
sumed to have occurred-before and after treatment
(SRM, 0.74-0.80) and in those patients who either
said that their problem was better overall or that their
ability to function had improved (SRM, 0.92-1.40)
(Table 4). Standards for a "good" or "large" respon-
siveness statistic have little meaning, because they
are dependent on the type of change being examined.
The distributions of the change scores are shown in
Figure 3. The large histogram shows the change for all
patients before and after treatment (whether they got
better or worse) as well as the change for the subgroups
of patients who said their problem was better and those
who said their function was better.
The DASH was found to have comparable or slight-
ly better responsiveness than the joint-specific meas-
ures; Table 5 and Figure 4 summarize these compar-
isons using the SRM statistic. When comparisons were
made at the subgroup level (by region of injury), the
DASH remained comparable with (only lower, by 0.04
to 0.08, in patients with wrist or hand conditions) or
better than the disease-specific measures.
Correlations between differences in the status
measures (self-ratings at follow-up minus self-ratings
at baseline) and the change scores on the DASH were
moderately high (Pearson r>0.65) (Table 6). Those
with the transitional indexes ("how are you now
compared to before") failed to meet our modest stan-
dard of 0.4 (correlations were in the range of
0.32-0.39) except in the overall rating of change in
their problem (Pearson r=0.40, Spearman r=0.43).
The correlations between the DASH scores and the
differences in state measures were of the hypothe-
sized magnitude; however, those between the transi-
Text continues on p. 138
April-June 200 I 135
 TABLE 4. Responsiveness of the DASH to Clinical Changes, Expressed as Mean (SD)
Baseline Follow-up Change Score Effect Size SRM
All patients completing baseline
and follow-up (n =172):
Observed change 44.5 (22.7) 30.9 (22.8) -13.3 (16.9) 0.59 0.78
Those rating problem as better (>6/10) 42.9 (22.9) 24.9 (20.2) -17.3 (16.4) 0.75 1.06
Those rating function as better (> 6/10) 40.7 (23.4) 20.2 (19.2) -19.7 (16.5) 0.84 1.20
Shoulder patients:
Observed change 48.3 (21.0) 35.3 (21.3) -13.4 (16.6) 0.64 0.81
Those rating problem as better (>6/10) 49.0 (20.9) 30.0 (19.5) -17.7 (15.7) 0.85 1.13
Those rating function as better (» 6/10) 49.1 (21.9) 24.3 (17.6) -23.7 (16.4) 1.08 1.44
Wrist/hand patients:
Observed change 33.8 (22.8) 20.5 (22.9) -13.0 (17.5) 0.57 0.74
Those rating problem as better (>6/10) 30.5 (22.2) 13.8 (17.2) -16.3 (17.8) 0.73 0.92
Those rating function as better (>6/10) 27.4 (19.4) 13.5 (20.3) -13.2 (14.5) 0.68 0.91
NOTE: The mean [and SDI for the DASH score at baseline and follow-up are shown, with the change score, effect size (mean change divid-
ed by SD of baseline), and standardized response mean (mean change divided by SD of change). Data are shown only for patients with data
for both baseline and 12-week follow-up. SRM indicates standardized response mean.

Number , . . - - - - - - - - - - - - - - - - - - - , - - - - - - - -- - ---,
eve change score = g. +ve change score =
40 less disability
III
~ more disability - - - - - -
110 _
30

20

10

o
<-50 40-4930-3920-2910-19 1-09 0 1-09 10-1920-2930-39
Change in DASH (observed change)

in those saying arm problem better (>6) (n=112) in those saying ability to function better (>6) (n=79)
35 35 ,----- -- - - - - - - - t - - - - - - - - ,
30 30 ------- - ----- ----- - - - - - - - - -- - - - - - -

25 25 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

20 20 -- --- --- -- - -

II
15 15

10

5
o
«so 40-49 30-39 20-29 10-19 1-09 0 1-09 10- 19 20-2930-39 <-50 40-4930-3920-2910-19 1-09 0 1-09 10-1920-29 30-39

Change in DASH Change in DASH

FIGURE 3. Number of subjects falling into lO-point score ranges for change in DASH scores, using 12-week follow-up data, for all
patients (top), patients who said their arm problem was better (bottom left), and patients who said they wereable to function better
(bottom right). A score of 0 (no change) is shown to provide an anchor.

136 JOURNAL OF HAND THERAPY

TABLE 5. Comparison of Responsiveness of the DASH and Two Joint-specific Measures, the SPADI and the Brigham,
Expressed as Standardized Response Means (SRMs)
DASH SPADI Function Score BrighamFLs
All patients:

Observed change 0.78 0.62 0.64

Those rating problem as better (>6/10) 1.06 0.84 0.86

Those rating their function as better (>6/10) 1.20 0.86 1.07

Shoulder patients:

Observed change 0.81 0.71 0.59

Those rating problem as better (>6/10) 1.13 0.95 0.83

Those rating function as better (>6/10) 1.44 1.13 1.24

Wrist/hand patients:

Observed change 0.74 0.43 0.76

Those rating problem as better (>6/10) 0.92 0.64 0.93

Those rating function as better (>6/10) 0.91 0.54 0.87

NOTE: The SRM (mean change score divided by SD of the difference) is used as the summary statistic; the SRM values are the same as those
shown in Table 4. SPADI indicates Shoulder Pain and Disability Index; FLs, functional limitations.

whole cohort _DASH

Observed DSPADI
change I:lBrigham

"Problem better"

"Function better"
................. ,., . ", .
..................................
..... ..
, ,
.. . ....... . . . ... ......... . . . ...........
., . ........... . ..
. . ........... . ..............
"
"
, , ,
.. , , ,
.
o 0.2 0.4 0.6 0.8 1 1.2 1.4
SRM
S h0 U Ider patienr-:-t-=-:s-:;-:-:----, wrisUhand patients
_ DASH _ DASH
C SPADI C SPADI
IUlBrigham IUlBrigham

~ ~
~ ~0
-.;f
",'" 0~
,q\# ,q\#
~ ~
~0 ~0
-.;f -.;f
~,-#, 0 0.2 0.4 0.6 0.8 1.2 1.4 !#' 0 0.2 0.4 0.6 0.8 1.2 1.4
,</:1 .«,"
SRM SRM

FIGURE 4. Responsiveness of the DASH compared with joint-specific measures (the SPADI and the Brigham function scores) for the
entire sample (top) and for patients by affected region-shoulder (bottom left) and wrist/hand (bottom right). Standardized response
meansareshown for the wholecohort (observed change), thosewho said their problem was better(n = 112), and thosewho said they were
ableto function better (n = 79).

April-June 200 I 137

 Table 6. Correlation Between Change in DASH Score and Change in Self-rated Pain, Function, and
Severity of Upper-limb Problem
Transition Scale Status Ratings Difference
Correlation
Change in Change in Change in Change in Change in Change in
Problem Pain Function Problem Status Pain Status Function Status
Pearson OAO 0.38 0.32 0.66 0.65 0.69

Spearman 0.43 0.37 0.39 0.60 0.62 0.63

NOTE: "Correlation" refers to the correlation with the change in DASH scores. Correlation was measured in two ways-first on an ll-point
transition scale (from "much worse" to "much better") at 12 weeks and then as the difference in status ratings (pain at 12 weeks minus pain
at baseline, each using a 7-point rating scale on both testing occasions). Pearson (parametric) and Spearman (ranked) correlations coefficients
are shown.

TABLE 7. Sensitivity and Specificity of Different Text continued from p. 135

Levels of Change
tional indexes and the change in DASH scores were
Sensitivity Specificity Accuracy (%) at or just below the expected level of 0.40.
x less than: The ROC curves, as shown in Table 7 and Figure 5,
<-1 0.92 0.29 48
also demonstrated that the change scores in the DASH
were more sensitive to ability to cope than to just
< -5 0.86 0.38 52 chance alone. In ROC curves, "chance" is equivalent
< -7 0.82 0.42 54 to the diagonal on the graph, where sensitivity equals
0.82
1 minus the specificity. Along this line the change
<-10 0.53 62
score gives no more information about who is better
< -15 0.67 0.68 68 and who is not than would chance alone (e.g., flipping
<-20 0.59 0.78 72 a coin). The point farthest up and off to the left from
the diagonal is often considered the most discriminat-
NOTES: The basis for comparison at different levels of change was a
"yes" answer to the question, "Are you able to cope with your prob- ing. In our graphs, a change score of at least -15 or -20
lem and do what you would like to do?" at follow-up after a "no" appears to be the most discriminative for the criterion
answer to the same question before treatment. x indicates the change of the patient's becoming able to cope; a score of -15
in DASH score. Sensitivity is the probability of having a change in
DASH score of x or less, given that the patient is better. Specificity is correctly rated 68% of the sample, and a score of -20
the probability of not having a change in DASH of x or less, given that correctly rated 72% (Table 7). Using the self-rated
the patient is not better. Accuracy is the percentage of patients whose scores (in which a score of more than 6 of 10 indicated
change score of x or less correctly classifies them as better or not bet-
ter. A change score of -15 or -20 was best able to discriminate improvement), as used in the statistical summary of
between those who were better and those who were not better, responsiveness, much lower change scores were
according to the selected criteria (see footnote on p. 133). found to be the most discriminating (for a change of
It is important to remember that a negative change score on the -lor a greater negative value, accuracy was 75%, sen-
DASH means less disability and, therefore, an improvement. Thus, a
change of less than -1 means just a little bit of improvement, and a sitivity 0.87, and specificity 0.44). This highlights the
change of less than -20 means a much greater improvement. effect of the external marker in this type of analysis.

Sensitivity
1

<-1
<-1 o~_----<..- <-5
0.8 -------------- ---- -------- ----- -<·-1 --- --------
FIGURE 5. Receiver operating characteristics
(ROC) curve describing the ability of different <15
amounts of change to differentiate between patients 0.6 - - - - - - < -20
who went from not coping to coping with their dis-
order (an improvement) and those who did not. The
"best" cut-off, in terms of accuracy, would be that 0.4
shown at the upper left of the curve. Changes of less
than -15 or -20 appeared most accurate on this
curve. Higher change scores were not assessed. 0.2

o
o 0.2 0.4 0.6 0.8
1- Specificity

138 JOURNAL OF HAND THERAPY

DISCUSSION
This study has provided evidence of the construct
validity, test-retest reliability and responsiveness of
the DASH Outcome Measure in patients undergoing
treatment for either proximal or distal disorders in
the upper limb.
Reliability, Validity, and Responsiveness
of the DASH
The DASH outcome measure exceeded recom-
mended standards for test-retest reliabilitr,25,34,41,67
for both individual- and group-level interpretation of
the scores." Generally, test-retest coefficients need to
exceed 0.90 or 0.95 before their interpretation on an
individual level can be considered. For group-level
interpretation, lower coefficients (approximately
0.75) are acceptable. 34,40 Our results provided a coef-
ficient of 0.96, which is only slightly higher than that
of Turchin et al. 19 (0.92 in patients with stable elbow
conditions), and these are not likely to be significant-
ly different in magnitude.
Evidence of both convergent and known-groups
validity of the DASH was also found. Convergent
validity was shown by demonstrating moderate to
high correlations with other markers of disability and
symptoms, and known-groups validity by showing
differences between the DASH scores of patients who
were working or functioning and the scores of those
who were not. The DASH validity was comparable
with previous results using this questionnaire in
other populations. The findings of Hudak et al. 16 and
Turchin et al. 19 and the results of the field-testing''
produced similar findings, although against a small-
er number of constructs.
The DASH was also responsive to the different
types of change designed into this study-specifical-
ly, change observed before and after treatment of the
target conditions and change in those patients who
said they were better.
Our results also highlighted two important issues
that concern responsiveness. First, the size of the
responsiveness statistic varied with the type of
change that was being quantified. The SRMs for
observed change were lower in magnitude than those
for the change in patients who said they were better.
This finding supports the taxonomy for responsive-
ness that we have presented elsewhere,55 which sug-
gests that instruments are "responsive to" different
types of change to different degrees. They do not
inherently possess a trait of being "responsive."
Comparisons of the responsiveness of different
instruments should only be conducted when similar
types of change are being tested or, ideally, when the
instruments are placed in a head-to-head comparison.
Second, our results also showed, as did Wright and
Young/" that the choice of statistic will affect the
description of responsiveness. For the same change
in the same patients, we demonstrated a variation up
to 1.33-fold in the responsiveness described by the
effect size statistic compared with the SRM (0.68 and
0.91, respectively). This difference would also span
the often used (or misused) guideline for what
Cohen68 calls a moderate vs. a large effect. However,
the difference in the numeric estimates we were com-
paring was attributable to the statistic chosen alone.
Responsiveness was also described by correlating
changes14,61 in the DASH with changes in three
attributes (pain, function, and problem), each meas-
ured in two ways-with transitional scales and with
difference-in-status measures performed at baseline
and at 12 weeks. Our results suggested a distinct dif-
ference between the transitional approach (correla-
tions of 0.32 to 0.43) and the difference-in-status
approach (correlations of 0.60 to 0.69). Given that the
concepts (pain and function) being measured using
the two approaches were the same, the differences
might be attributed to the way the questions were
asked (transition vs. difference in status), leading to
several possible explanations. Differences in a transi-
tional approach vs. differences in status over time
could be due to recall bias69,7o or to a change in how
people cognitively formulate a response when asked
to describe a current state as 0fJosed to recalling a
change in that state over time.6, -74 Changes in how
people calibrate or define pain, health, and quality of
life over time have been described in the literature
(e.g., "response shift phenomenon,,75-77) and could
have influenced our results.?5-80 All these things
could be possible reasons for the difference in the
correlations between the change in DASH score and
the two approaches to determining whether change
had occurred (difference in serial state measures vs.
the transition style of constructs). We are not sug-
gesting which is better; arguments can be made in
both directions. 69,77,81-83 Like Fischeret al.,84 we have
demonstrated the difference in the two approaches
and, like them, we do not have evidence to suggest
which is better.
The DASH in Comparison with
Joint-specific Measures
The DASH had high correlations with the two
joint-specific measures, the Brigham and the
SPADI-a pattern that persisted when the joint-spe-
cific measure was applied in the other region
(Brigham vs. DASH in shoulder patients, 0.90; SPADI
vs. DASH in wrist patients, 0.92). Therefore, our
hypothesis that there would be a difference in the
correlations when the joint-specific measures were
applied in the wrong joint was not supported.
On a cross-sectional basis, the joint-specific meas-
ures performed well in the "wrong" joint. To our
knowledge, this is the first time joint-specific meas-
April-June 200 I 139
ures in the upper limb have been purposefully
applied to the "wrong" joint. Our results support our
earlier findings that items from joint-specific ques-
tionnaires could not be identified as relevant to only
one joint in the extremity by a panel of experienced
clinicians.' In that study, experts classified over 70%
of the items they were given (e.g., using a phone) as
being potentially affected by impairments across the
upper extremity and not just to problems in one joint;
that is, using a phone might be a relevant item for
patients with shoulder, elbow, or grasp problems.
The results of our current study show similar results,
but at the whole questionnaire level. The items in the
Brigham appear to be sensitive to impairments in the
shoulder, and the items in the SPADI appear be sen-
sitive to impairments in the wrist.
The responsiveness of the DASH, with two excep-
tions, was also comparable with or better than that of
the joint-specific measures. The exceptions were in
the group of patients with wrist or hand problems, in
which the SRMs for the Brigham were slightly high-
er than for the DASH for two of the three compar-
isons (observed change, 0.02 higher for the Brigham;
change in those who rated their problem as better,
0.01 higher).
Many would consider the values comparable; the
difference would not be statistically significant.
Nevertheless, in 16 of 18 comparisons between the
DASH and the joint-specific measures, the DASH sta-
tistics were larger. The Brigham questionnaire was
also responsive to changes in patients with shoulder
problems (although its responsiveness was lower in
magnitude than that of the DASH). The SPADI
showed only moderate SRMs (0.43 to 0.64) in the
patients with wrist or hand problems, whereas the
SRMs of both the DASH and the Brigham were larger
(SRM ±0.74). Both the Brigham and the SPADI
appeared responsive outside their region of specialty.
These results suggest that the responsiveness of the
DASH was equivalent to that of both joint-specific
measures and better than that of either in the whole
cohort, affirming its utility for patients with any sin-
gle or multiple disorders in the upper limb. These
findings are slightly different from those of Kirkley et
al. 14 or MacDermid et al.}O who found the DASH
slightly less responsive than a disease-specific meas-
ure (although a different disease-specific measure
was used in each case).
The implications of our findings are two-fold. First,
the DASH has potential in the role of monitoring
physical function and symptoms in shoulder and
wrist or hand disorders, as demonstrated by its valid-
ity, high test-retest reliability, and responsiveness to
even small changes early in the recovery process.
This provides a practical solution to the problems of
having to use multiple measures in patients with
multiple impairments and of having to have multiple
140 JOURNAL OF HAND THERAPY
upper extremity measures available in a clinic or
research setting.
Second, the high levels of reliability (the Cronbach
alpha was 0.97 at baseline in this study) indicate that
a much shorter measure could have acceptable relia-
bility34 with less respondent burden. The longer ver-
sion will probably always retain a statistical psycho-
metric advantage; however, the shorter might pro-
vide a more useful version for studies that entail a
significant respondent burden, such as epidemiolog-
ic surveys and detailed outcome studies.
This study has demonstrated that the DASH out-
come measure has good construct validity, test-retest
reliability, and responsiveness to change (specifically
change before and after four groups of treatments as
well as change that was estimated to have occurred
by the patients). This evidence has been provided for
both proximal and distal disorders, which suggests
that the DASH has a role as a measure of physical
function and symptoms in any single or multiple dis-
orders of the upper limb. Further work will focus on
its use with other patient groups and on the interpre-
tation of specific scores at the individual level.
Acknowledgments
The authors thank Ms. Elaine Harniman in Toronto and
Ms. Joanne Nicklas in Boston, who implemented the study
protocol. They also thank Dr. Robin Richards, Dr. James
Mahoney, and Dr. Mike McKee for allowing them access to
their patients; Dr. Louis Bessette, who contributed to the
conceptualization and design of this project; and the
patients who participated in the project.
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Appendix
THE DASH

The complete text of the Disabilities of the Arm, Shoulder and Hand questionnaire (© 1997) appears on the follow-
ing pages. It includes 30 items and two optional modules-the high-performance / sports module and the work
module. The DASH was developed jointly by the Institute for Work & Health (Toronto, Ontario, Canada) and
the American Academy of Orthopaedic Surgeons (Rosemont, Illinois), who both hold the copyright, and it is
reprinted here with their permission.

142 JOURNAL OF HAND THERAPY