Frequently Asked Questions
The DASH and QuickDASH Outcome Measures are available free of charge provided they are not sold or incorporated into a product that is sold. The DASH and QuickDASH can be downloaded from the DASH website at www.dash.iwh.on.ca. The conditions for use of the DASH are that: 1) the DASH be used in its original form without any changes; and 2) the Intent to Use Form (also available online) is completed and submitted to the Institute for Work & Health.
At this time, we do not recommend or endorse using the DASH/QuickDASH over the telephone. The DASH/QuickDASH was designed to be completed in paper and pencil format. Comparability of scores of the paper and pencil format with telephone administration has not yet been formally tested.
The DASH and QuickDASH were designed to be disability questionnaires. As such, scaling was ranked from 0 indicating least disability to 100 indicating most disability. Other instruments may be designed to measure functional status or health in which case they might wish to have a high level of health described by a higher number (100). When using a measure, you should always be aware of the direction of the scales.
Confidentiality is a very important issue. An explanation of how the information will be used should be provided before respondents complete the DASH or QuickDASH. Sometimes the administration of the DASH/QuickDASH is part of routine care and the forms are approved for use in a hospital or clinic. In research settings, responses might be kept only for use in a particular study. Usually, the use of patient information is explained in a consent form for the study. In this situation, reassure respondents that their answers will remain strictly confidential and explain that strategies are in place to ensure this. As an example, surveys are often kept under double-lock and respondents' names do not appear on the questionnaire – only a study identification number appears.
We recommend that you tell the respondent to leave the item blank if it is offensive. We have had the greatest problem with the Sexual Activities question. We see it in missing values. However, patients told us that we needed to include it because it is an important part of their lives that is impacted by their upper-limb pain. We are therefore keeping it in for now. However, we recognize that it is left missing about 20% of the time. Other times it serves to open a door for the patient to talk about this aspect of the impact of the disorder with their health-care provider. When scoring, the items that are left blank are simply treated as missed items and counted in the number allowed to be missed in the scoring process.
The DASH and QuickDASH evaluate upper-limb disability and symptoms. Items are not attributed to the affected limb because at the level of disability, as defined by the Disable-ment Process (Jette 1994; Verbrugge 1994), we want to know an individual's ability to do activities regardless of which arm, shoulder or hand they use. The intent of the DASH and QuickDASH is to determine how much difficulty a patient has when doing an activity, regardless of how it is done.
The DASH and QuickDASH are designed to measure the capacity to do things, because we recognize that each individual may not have performed the actual activity during the past week. Ask respondents to rate their ability to do the task. For example, ask, “If you had done that task, how much difficulty would you have had?” Often patients will say that they didn’t do it because they weren’t able to do it. Such a response would equate to a score of 5 = unable.
Granted, persons with upper-limb disorders often use assistive devices, such as splints or specialized equipment, to improve their ability to perform activities. In fact, some measures, while permitting the use of an assistive device, subsequently weight the patient’s score on that basis (Fries 1982). The intent of the DASH/QuickDASH is to determine how well a person can do an activity regardless of how it is done. Respondents are therefore asked to rate their ability using the assistive device if that is their usual practice at the time. However, this approach does not allow them to rate their ability when the assistance of another person is involved. The use of an assistant is arguably more a reflection of the environment than of the autonomy of the person with the disability. In this situation, respondents are asked to rate their own ability rather than their assisted ability.
Explain that the DASH/QuickDASH has been designed to measure change over time. Taking scores at different times will help to determine how the care/intervention that they are receiving is affecting their level of disability and/or symptoms.
The answer to this question really depends on your qualifications and/or your role. If your sole role is to collect data, you should refer respondents to their clinician/physician. However, if you are the respondent’s health-care provider, you could explain to him or her that some of the most helpful information is found by looking at each of the items individually to see which ones were scored as being difficult. Often these item scores are useful in goal setting. Over time the score may change, reflecting a change in the responses to some of the items. These could be examined to see which items have shown improvement.
The minimum clinically important difference (MCID) is considered the smallest change or difference in an outcome measure that is perceived to be important (Wells 2001). There are different methods (Wells 2001) and viewpoints (patient, clinicians) that may be used to determine the MCID. We have found considerable variability due to the effect of the method used, of the time window, and of whether the change was important or not (with DASH MCID values ranging from 3.9 to 15). These are important differences, and this variability is likely is present in many other tools as well but never tested. Our work has shown us that there is reason to be skeptical about hard and fast claims of a single MCID value. However, when we worked through all the findings, we decided that a change in DASH score exceeding 15 points is the most accurate change score for discriminating between improved and unimproved patients (Beaton 2001a; 2001b). This and other indicators place the MCID at, or below, our current understanding of the minimal detectable change at the 95% confidence level (MDC95). The MDC can be computed at varying confidence levels. It is the minimum change score that must be observed before a clinician can be confident that a change in patient status has occurred rather than measurement error (Beaton 2000c). An individual-level change below the MDC is difficult to interpret because it could just be the day-to-day variability in the score rather than an important change. Since some MCID work is placing the MCID at approximately the same value as the MDC95, it is reasonable to consider the MDC95 as an interim proxy for the MCID. MDC95 was calculated for the DASH across six different study populations and ranged from 8 to 17 DASH points (with a mean of 13).
For the QuickDASH, we have approached the clinically important change question in the same manner. To date, only one study has looked at the MCID of the QuickDASH and reported that a change exceeding 8 points is the most accurate change score for discriminating between improved and stable patients (Mintken 2009). Since this study is placing the MCID at a value lower than the MDC95, it is reasonable to consider the MDC95 as an interim proxy for the MCID. MDC95 was calculated for the QuickDASH across three different study populations and ranged from 16 to 20 QuickDASH points (with a mean of 18).
One common approach for assessing magnitude of change is using minimal clinically important difference (MCID) or the minimal detectable change (MDC). For more information about MCID and MDC, see the above Frequently Asked Question: What is considered to be a clinically important change for the DASH/QuickDASH? This approach focuses on the interpretation of change scores. A bigger change score means you are better!
However, how often do our patients tell us that they are better when they can do X – be it use a certain tool, open jars or hold their children? These are final states. Some researchers have introduced the concept of reaching a threshold for a successful endpoint (or final state). If the final score is examined for its interpretability, we would suggest using anything less than 10.1 (the mean DASH score in a large general population survey). For more information about the DASH normative data, see the above Frequently Asked Question: Are there normative values for the DASH?
Work by Jacobson (1999), however, reminds us that we need two conditions to declare that a person has responded to treatment. First, we need to induce a change – or in other words see that our treatment has caused a change. Second, the change must put the person/patient in a good place. The good place could be within normal values, or for example, no longer in the range of scores expected for people who are depressed. In order to achieve both of these conditions, Jacobson’s work has suggested that we combine the MDC (change above which it is not likely just day-to-day variability in score) and final state (landing within the general population norms on the DASH, for example).
We believe this is what clinicians are doing when they are looking at the graphs over time. Clinicians can see change, and we can tell them when change is greater than the MDC by the shaded bars in the figure. Also, they can see how close the person is to normal values. In addition, they are able to get a sense of how fast someone reaches their goals. Here, clinical intuition meets measurement sciences. Comparisons between the combined approaches and the MCID show that the combined approach is less sensitive to subtle change, as expected, and more specific in its ability to pick up true improvement (Beaton 2010, in press).
Normative data for the DASH Outcome Measure have been collected in a large general population survey conducted by the AAOS. The results have been published by Hunsaker (2002). Hunsaker reported that the general population would score 10.1 on the DASH with a standard deviation of 14.68.
At present there are no divisions to categorize scores as excellent, good or fair or mild, moderate or severe disability. Other benchmarks and means of interpretation are available.
The DASH and QuickDASH were developed to assess upper extremity disabilities in adults. While there is no set age limit, general guidelines are 18 to 65 years of age.
Both tools are valid, reliable and responsive and can be used for clinical and/or research purposes. However, because the full DASH Outcome Measure provides greater precision, it may be the best choice for clinicians who wish to monitor arm pain and function in individual patients.
There are people who have developed unofficial versions of the DASH/QuickDASH. By unofficial, we mean they may have created their own shortened form and called it the DASH (Weigl 2006), modified DASH (Colovic 2008) or modified QuickDASH-9 (Gabel 2009).
Other unofficial versions may have reported adaptations to the scoring of the DASH. One version has made changes to the response options from a 5-point scale to a visual analogue scale (Matheson 2006). A version of the Swedish translation of the DASH reported an adaptation to scoring by creating two subscale scores, DASH activity (21-items) and DASH symptoms (9-items) (Sandqvist 2009). Similarly, a version of the German translation of the DASH have also reported an adaptation to scoring by creating two subscales, functional activities and symptoms (Germann 2003; Jester 2005). Another unofficial version has modified the DASH scoring to be weighted according to a patient’s priorities, by rating the importance of each item on a 5-point scale, and calling it the patient-specific DASH (PS-DASH) (Vranceanu 2010).
We work on an honour system and provide the DASH free of charge. When you download the DASH/QuickDASH, you agree to retain its original format. In order to help us deliver accurate information about the tool’s performance, we need to focus only on the sanctioned versions. The cost of testing and maintaining every unofficial modification would be too much for us to manage – particularly when the original versions (DASH/QuickDASH) seem, based on the testing by our group and by others, to be doing quite well.
References to unofficial versions of DASH/QuickDASH Outcome Measure — not supported by IWH:
Colovic H, Stankovic I, Dimitrijevic L, Zivkovic V, Nikolic D. The value of modified DASH questionnaire for evaluation of elbow function after supracondylar fractures in children. Vojnosanitetski Pregled 2008; 65(1):27-32.
Gabel CP, Burkett B, Yelland M, Melloh M. A modified QuickDASH-9 provides a valid outcome instrument for upper limb function. BMC Musculoskeletal Disorders 2009; 10:161
Germann G., Harth A., Wind G., Demir E. Standardisation and validation of the German version 2.0 of the Disability of Arm, Shoulder, Hand (DASH) questionnaire. Der Unfallchirurg 2003; 106(1):13-9.
Jester A, Harth A, Wind G. Germann G. Sauerbier M. Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire: Determining functional activity profiles in patients with upper extremity disorders. Journal of Hand Surgery - British Volume 2005c; 30B(1):23-28.
Yes, but in order to have a translation that can be called the “DASH/QuickDASH,” a specific protocol must be followed. Guidelines for cross-cultural translation, which are available through the Institute for Work & Health, have been published by Beaton (2000d). The Institute reviews the procedures used for translation and grants approval. This process is time-consuming and resource intensive, so check with the Institute for approved translations before embarking on this process. To date, official translations are available in 27 languages.
If you have explained the importance of completing the DASH/QuickDASH and how it could help, then there is nothing more that you can do. It is unethical to force someone to comply in a clinical or research setting. If a patient explains why he or she does not wish to fill out the DASH/QuickDASH, please record the comments on the questionnaire.