Construct validity and reliability of the disability of arm, shoulder and hand questionnaire for upper extremity complaints in rheumatoid arthritis.

Abstract

The Disability of Arm, Shoulder and Hand (DASH) questionnaire is a tool for measuring physical function and symptoms of the upper extremity. Although widely used, it is not validated for rheumatoid arthritis (RA). In this study the DASH was validated for this patient group.
In total, 102 patients participated in this study. For the validation, the questionnaires of the DASH, the Health Assessment Questionnaire (HAQ), the Medical Outcomes Study Short Form-36 (SF-36), and the Arthritis Impact Measurement Scale (AIMS2) were used. Patients were examined clinically before completing the questionnaires. Pain was scored by each patient using a visual analog scale (VAS). The Disease Activity Score (DAS28) was obtained and grip strength was measured. Reliability was tested by a second DASH questionnaire after 2 days. Validity was tested using a Pearson correlation analysis for the relevant domains of the questionnaires and for the clinical aspects.
The reliability of the DASH was excellent (intraclass correlation coefficient 0.97). Internal consistency was strong (Cronbach's alpha 0.97). Validity was proven with excellent results for Pearson correlation with the relevant domains of the questionnaires: HAQ, r = 0.88; SF-36, r = 0.70; and AIMS2, r = 0.85. The clinical scores had a relatively low correlation with the DASH (DAS28, r = 0.42; and grip strength, r = 0.41-0.48), except for the VAS (r = 0.60-0.65).
The DASH is a reliable and valid questionnaire in patients with RA. It can be used as a measurement tool of physical disability of the upper extremity.

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Raven, et al: Validity and reliability of DASH
Construct Validity and Reliability of the Disability of
Arm, Shoulder and Hand Questionnaire for Upper
Extremity Complaints in Rheumatoid Arthritis
ERIC E.J. RAVEN, DANIËL HAVERKAMP, INGER N. SIEREVELT, DOUWE O. van MONTFOORT, RUUD G. PÖLL,
LEENDERT BLANKEVOORT, and PAUL P. TAK
ABSTRACT. Objective. The Disability of Arm, Shoulder and Hand (DASH) questionnaire is a tool for measuring
physical function and symptoms of the upper extremity. Although widely used, it is not validated for
rheumatoid arthritis (RA). In this study the DASH was validated for this patient group.
Methods. In total, 102 patients participated in this study. For the validation, the questionnaires of the
DASH, the Health Assessment Questionnaire (HAQ), the Medical Outcomes Study Short Form-36
(SF-36), and the Arthritis Impact Measurement Scale (AIMS2) were used. Patients were examined
clinically before completing the questionnaires. Pain was scored by each patient using a visual ana-
log scale (VAS). The Disease Activity Score (DAS28) was obtained and grip strength was measured.
Reliability was tested by a second DASH questionnaire after 2 days. Validity was tested using a
Pearson correlation analysis for the relevant domains of the questionnaires and for the clinical
aspects.
Results. The reliability of the DASH was excellent (intraclass correlation coefficient 0.97). Internal
consistency was strong (Cronbach’s alpha 0.97). Validity was proven with excellent results for
Pearson correlation with the relevant domains of the questionnaires: HAQ, r = 0.88; SF-36, r = 0.70;
and AIMS2, r = 0.85. The clinical scores had a relatively low correlation with the DASH (DAS28,
r = 0.42; and grip strength, r = 0.41–0.48), except for the VAS (r = 0.60–0.65).
Conclusion. The DASH is a reliable and valid questionnaire in patients with RA. It can be used as
a measurement tool of physical disability of the upper extremity. (J Rheumatol First Release Nov 1
2008; doi:10.3899/jrheum.080067)
Key Indexing Terms:
CONSTRUCT VALIDITY
RHEUMATOID ARTHRITIS
DISABILITY OF ARM, SHOULDER AND HAND
DASH
From the Orthopaedic Research Center Amsterdam, Department of
Orthopaedic Surgery, Academic Medical Center, Amsterdam; Department
of Orthopaedic Surgery and Traumatology, Gelre Hospital, Apeldoorn;
Department of Orthopaedic Surgery, Slotervaart Hospital, Amsterdam;
and Division of Clinical Immunology and Rheumatology, Academic
Medical Center/University of Amsterdam, Amsterdam, The Netherlands.
E.E.J. Raven, MD, Orthopaedic Research Center Amsterdam, Department
of Orthopaedic Surgery, Academic Medical Center, Amsterdam,
Department of Orthopaedic Surgery and Traumatology, Gelre Hospital;
D. Haverkamp, MD, PhD; I.N. Sierevelt, MSc; D.O. van Montfoort, MD,
Orthopaedic Research Center Amsterdam, Department of Orthopaedic
Surgery, Academic Medical Center, Amsterdam; R.G. Pöll, MD, PhD,
Department of Orthopaedic Surgery, Slotervaart Hospital; L. Blankevoort,
PhD, Orthopaedic Research Center Amsterdam, Department of
Orthopaedic Surgery, Academic Medical Center, Amsterdam; P.P. Tak,
MD, PhD, Division of Clinical Immunology and Rheumatology, Academic
Medical Center/University of Amsterdam.
Address reprint requests to Dr. E.E.J. Raven, Department of Orthopaedics
and Traumatology, Gelre Hospital, PO Box 9014, 7300 DS Apeldoorn,
The Netherlands. E-mail: e.raven@gelre.nl
Accepted for publication July 10, 2008.
Orthopedic surgeons and rheumatologists are increasingly
interested in determining the outcome of their interventions,
whether surgical or nonsurgical. Several disease or site-spe-
cific subjective outcome measures are available. For
patients with rheumatoid arthritis (RA) several question-
naires were developed to measure quality of life and physi-
cal disability. Those questionnaires are not specific to the
site of the disease. Especially in patients with RA, disease
activity in the upper extremity can be very invalidating.
Hand and wrist symptoms are present in 43% and shoulder
symptoms in 9% of these patients1-3.
For independence, good functioning of the upper extrem-
ity during daily living is of utmost importance; therefore, a
good standardized assessment is required. The Disability of
Arm, Shoulder and Hand (DASH) is a questionnaire devel-
oped and validated in 1994 by the American Academy of
Orthopedic Surgeons, the Council of Musculoskeletal
Specialty Societies, and the Institute for Work and Health4.
This questionnaire focuses on functional status and symp-
toms rather than one specific anatomic region or specific
disease entity. The rationale for the development of the
DASH was that the upper extremity is to be considered as
one functional unit5. The DASH was developed to measure
physical disability and symptoms of the upper limbs in a
heterogeneous population, i.e., men and women, and indi-
viduals with mild, moderate, or severe disability and a wide
variety of upper extremity disorders6. The purpose of the
DASH questionnaire is to describe differences between

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groups of individuals in order to compare the effects of
upper limb disorders and to compare outcomes in clinical
studies.
Since 1996 the questionnaire has been translated and val-
idated in many countries and languages and for different dis-
orders of the upper extremity7-9. In addition, construct valid-
ity and responsiveness have been tested10. However, in
these studies, the presence of RA was an exclusion criteri-
on7,9, or a subgroup analysis for RA patients was not
possible8,10.
Availability of the DASH for the population of RA
patients with upper extremity disorders would be an excel-
lent expansion of the subjective outcome measurements for
this group, since no upper extremity-specific subjective
score is available yet. However, construct validity and relia-
bility of the DASH cannot be assumed for the RA patient
group, since it includes patients with pathology that is often
diverse and multifocal, who are not comparable to otherwise
healthy patients with isolated upper extremity disorders.
Before using the questionnaire for this specific population,
a proper validation should be performed to test whether the
outcome measurement is valid for this population. We eval-
uated whether the DASH is a valid outcome instrument for
upper extremity disability in patients with RA.
MATERIALS AND METHODS
Patients and assessment of health status. We investigated construct validi-
ty and reliability of the Dutch DASH in RA patients who were rheumatoid
factor-positive. For this purpose a consecutive group of patients visiting the
outpatient clinic of the Academic Medical Center, the Slotervaart Hospital
(a large non-academic hospital with special interest in RA), or the Jan van
Breemen Institute (an outpatient clinic focused on RA and rehabilitation
medicine) with rheumatoid factor-positive RA and pain of the upper
extremity were asked to participate in the study. A total of 122 patients
agreed to participate, of whom 102 (84%) completed and returned the ques-
tionnaires. The average age of respondents was 57.5 years (range
22.6–86.4) and 63.9% of respondents were female.
Besides the DASH, the questionnaire used was constructed from the
36-item Short Form health survey (SF-36), the Health Assessment
Questionnaire (HAQ)11, the Arthritis Impact Measurement Scales
(AIMS2)12, and a 100 mm visual analog scale (VAS) for pain. Additionally,
all patients were clinically examined according to the Disease Activity
Score (DAS28)13and grip strength was measured.
The DASH is a self-administered site-specific questionnaire consisting
of 30 questions to be answered by the patient concerning general function-
ing, and it is focused on the upper extremity and is entirely subjective. It
includes 21 physical function items, 6 symptom items, and 3 social
role/function items. Each question consists of a 5-point Likert scale, lead-
ing to a total score from the best functional score of 30 to the worst func-
tional outcome of 150. In order to simplify the results, the score is divided
by the number of responses, subtracted with 1, and then multiplied by 25.
This gives a best possible score of 0 and a worst possible score of 100.
The 28-joint Disease Activity Score, DAS28, is based on counts of the
number of tender (TJC) and number of swollen (SJC) joints (of 26 upper
extremity and knee joints) found on examination by the physician, the C-
reactive protein (CRP value), and the patient’s global assessment using a
visual analog scale (VASDAS)14.
The SF-36 is a general health questionnaire consisting of 36 Likert box
questions15-18. The questionnaire contains 8 health concepts: physical func-
tioning (PF), role limitation due to physical problems (RP), bodily pain
(BP), perception of general health (GH), energy and vitality (VT), social
functioning (SF), role limitation due to emotional problems (RE), and men-
tal health (MH). The results of the SF-36 range from the worst outcome, 0,
to the best outcome, 10015,17.
The Stanford HAQ11measures difficulty in performing activities of
daily living. It consists of 20 questions on daily functioning during the past
week. There are 8 component areas: dressing and grooming, arising, eating,
walking, hygiene, reach, grip, and outdoor activity. Each response is scored
on a 4-point scale of ability, range 0 to 319.
The AIMS212,20-23was designed to measure the health status compo-
nent of outcome in a multidimensional fashion using specific scales, sum-
mary components, and overall impact measures. The AIMS2 has been val-
idated for the Dutch language21. The current AIMS2 instrument is a 78-
item questionnaire; the first 57 items are divided into 12 scales: mobility
level, walking and bending, hand and finger function, arm function, self-
care tasks, household tasks, social activity, support from family and friends,
arthritis pain, work, level of tension, and mood. It is also possible to recode
the results in 3 scales: physical (mobility level, walking and bending, hand
and finger function, arm function, self-care, household tasks), affect (level
of tension, mood), and symptom (arthritis pain). For validation of the
DASH, only the first 3 scales were used.
To determine the seriousness of the pain in the right and left upper
extremity, a 100 mm VAS was used24.
Grip strength was measured using a Jamar meter (Asimow Engineering,
Los Angeles, CA, USA). All patients had to squeeze 3 times with each
hand; the mean peak measure of these efforts was considered the grip
strength.
The time and effort required to complete the questionnaire was record-
ed by the patient in order to determine the burden to the patient. A lengthy
time required to complete the questionnaire implied a high burden.
For an indication of health status, we calculated the mean, standard
deviation, and minimum and maximum of the DASH, DAS28, CRP, HAQ,
AIMS-PF, AIMS-Affect, AIMS-Symptoms, SF-36-PF, SF-36-BP, SF-36-
SF, and SF-36-RP.
Validation of DASH in RA patients. Reliability is defined as the ability of a
test to yield the same results on repeated trials under the same conditions25.
To determine retest reliability, the patients completed the DASH twice; 2
days after the first completion, patients had to fill out the questionnaire
again. This 2-day period was chosen because the status of RApatients may
vary over a longer period and reliability needs to be tested under the same
conditions. The test-retest reliability was expressed as the intraclass corre-
lation coefficient (ICC)26and the Bland-Altman coefficient of reliability27.
T-tests were performed to determine the systematic difference between the
first and the second test.
Internal consistency was assessed to determine whether all the ques-
tions cover the same construct. Internal consistency was assessed by
Cronbach’s alpha28, which confirmed the homogeneity of the questions
included in the questionnaire and is complementary to the ICC as a meas-
ure of reliability. An alpha finding of 0.7 is considered to represent a fair
degree of internal consistency, 0.8 is considered good, and 0.9 would rep-
resent excellent internal consistency29.
Construct validity addresses the ability of a questionnaire to measure
the outcome parameter of interest. It was tested by comparing the DASH to
the DAS28, SF-36, HAQ, AIMS2, a 100 mm VAS for pain, and the mean
grip strength. The 8 domains of the SF-36 were used to assess convergent
and divergent validity of the DASH. We evaluated this by hypothesizing
that correlation coefficients between the study questionnaire and the SF-36
domains bodily pain (BP), role of physical limitations (RP), and physical
functioning (PF) were higher than correlations with other domains. This
was also done with the 3 main scales of the AIMS2. We hypothesized that
the DASH would correlate better with AIMS2 scales of physical function-
ing than the AIMS2 scales of affect and symptom.
Content validity addresses whether a questionnaire has enough items
and adequately covers the domain of interest. Content validity was evalu-
ated by assessing the distribution and floor and ceiling effects of the DASH.
2
The Journal of Rheumatology 2008; 35:12; doi:10.3899/jrheum.080067

Page 3

A floor effect occurs when the patient scores the lowest possible score (0),
and therefore the patient appears to have no upper extremity disability. The
ceiling effect is the highest possible score (100), and is thus the opposite of
the floor effect29.
Statistics. Statistical analysis was performed by using SPSS (version 12.01;
SPSS Inc., Chicago, IL, USA). Ap value < 0.05 was considered statistical-
ly significant.
RESULTS
The mean, standard deviation, minimum and maximum of
the DASH, DASH retest, DAS28, grip strength, CRP, HAQ,
AIMS-PF, AIMS-Affect, AIMS-Symptom, SF-36-PF, SF-
36-BP, SF-36-SF, and SF-36-RP were all normally distrib-
uted (Table 1).
Reliability. The ICC of the questionnaire was very high at
0.97 (95% CI 0.96–0.98). No statistically significant differ-
ence was found between the 2 assessments (p = 0.6). The
Bland-Altman coefficient of reliability was 0.58 (95% CI
–1.03 to 2.20). Cronbach’s alpha showed that the question-
naire had strong internal consistency, with a value of 0.97
(95% CI 0.96–0.98).
Construct validity. The correlation of the DASH with the
DAS28 was r = 0.42 (p < 0.01; Table 2). Two of the 4 com-
ponents of the DAS28 correlated positively with the DASH,
i.e., the number of tender joints and the VASDAS (Table 3).
The physical components of the SF-36 (PCS) correlated
strongly with the DASH score (r = –0.70, p < 0.01). Three
out of 4 parts of the physical component correlated well
with the DASH (physical functioning, r = –0.67; bodily
pain, r = –0.68; social functioning, r = –0.63; p < 0.01). Only
role limitation (RP) had a moderate correlation (r = –0.44, p
< 0.01). The correlation between the DASH and the mental
correlation score was r = –0.27 (p < 0.01), whereas the gen-
eral health score showed a moderate correlation (r = –0.53,
p < 0.01).
The HAQ had the strongest Pearson correlation with the
DASH (r = 0.88, p < 0.01). Consistent with the relationship
between DASH and SF-36, the physical part of the AIMS2
had a high correlation with the DASH (r = 0.85, p < 0.01).
The symptom component had a marked correlation (r =
0.67). The affect part had a rather low correlation (r = 0.55).
The dominant arm VAS for pain correlated well with the
DASH score (r = 0.61). The left and right arm correlations
were similar (r = 0.60, r = 0.65, respectively).
The grip strength correlation with the DASH was low
(right, r = 0.41; left, r = 0.49; Table 2).
Content validity. The scores of the DASH questionnaire were
normally distributed. Ceiling and floor effects were not observed.
Scores ranged from 0 to 92, where 2 of the 102 patients had a
score of 0. The mean DASH score was 39.0 (SD 21.4).
Burden. Median time to complete the DASH was 6 minutes.
In our patient group, 12% had some difficulty or needed
assistance with completing the questionnaire. The Pearson
correlation of the DASH with the time required to complete
the questionnaire was moderate (r = 0.47), indicating that
the burden was partly caused by disease activity.
DISCUSSION
The aim of this study was to validate the DASH question-
naire for upper extremity complaints in patients with RA.
The questionnaire was previously translated and validated in
Dutch and several other languages, but not evaluated in
patients with RA. Reliability and construct validity were
tested in a group of 102 consecutive patients in 3 clinics.
The reliability and validity of the Dutch DASH for RA
patients were found to be excellent.
It is well known that RApatients may have fluctuation in
the severity of their complaints. Therefore, a short period of
2 days was chosen between the 2 testing times, instead of a
longer period. The possible consequence may be that the
reliability is somewhat overestimated. However, the internal
consistency was similar to that of the original American ver-
sion5, and to that reported in other validation studies7,10.
The construct validity of the DASH was tested by corre-
lating its outcome to the relevant dimensions of the SF-36,
the HAQ, and the AIMS2 questionnaires. The correlation
with the physical function aspect of the SF-36 was compa-
rable with the construct validity reported by other investiga-
tors in different patient groups and for other languages7,30.
However, the physical component score and bodily pain
showed different correlations with the DASH in several
studies7,30(Table 4).
The correlation between the DASH and the HAQ was
comparable with the results of a study in which the German-
language version of DASH was validated7(Table 4). The
HAQ showed a better correlation with the DASH than the
physical components of the SF-36. This may be because the
SF-36 addresses general physical health rather than specific
regional questions about the upper extremity like the HAQ.
3
Raven, et al: Validity and reliability of DASH
Table 1. Health status.
ScoreMean SDMinimumMaximum
DASH baseline
DASH retest
DAS28
Grip strength left
Grip strength right
CRP
HAQ
AIMS-PF
AIMS-Affect
AIMS-Symptoms
SF-36-PF
SF-36-BP
SF-36-SF
SF-36-RP
39.0
37.5
3.1
14.4
15.1
14.5
1.2
3.7
3.2
5.3
46.5
46.1
65.5
31.9
22.2
23.7
1.23
10.6
10.7
20.4
0.73
2.1
1.8
2.6
28.3
24.4
26.2
39.9
0.0
0.0
0.41
0
0
1.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
92.50
94.5
6.68
40.7
40.7
118.0
2.9
9.2
8.8
10.0
100.0
100.0
100.0
100.0
DASH: Disability of Arm, Shoulder and Hand; CRP: C-reactive protein;
HAQ: Health Assessment Questionnaire; AIMS: Arthritis Impact
Measurement Scale; PF: physical functioning; SF-36: Medical Outcome
Study Short Form 36.

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The good correlation of the DASH with the physical parts of
the AIMS2, an arthritis-specific instrument, supports the
DASH as suitable to use in patients with RA.
Although the SF-36 PCS showed construct validity equal
to both AIMS physical functioning/symptom and HAQ
compared to the DASH, the correlation with the VAS scores
for pain in the upper extremity was superior to the DASH
compared to the HAQ. The 3 domains of the AIMS showed
a construct validity completely comparable to the DASH,
but the burden of answering the AIMS can be considered
higher, because it contains more questions. Therefore, if one
is interested only in upper extremity complaints, the DASH
could be more suitable than the HAQ or AIMS.
Low correlations were found between the DASH and the
DAS28 and the grip strength measure. This is comparable
with others’ results7,31, suggesting a weak correlation
between the DASH and clinical outcome measures. An
explanation for this would be that disability is dependent not
only on disease activity, but is also related to joint destruc-
tion, especially in more advanced disease.
4
The Journal of Rheumatology 2008; 35:12; doi:10.3899/jrheum.080067
Table 2. Pearson correlation coefficients between the DASH score, SF-36, HAQ, AIMS2, DAS28, VAS, and grip strength.
DASH HAQAIMS-PFAIMS-AffectAIMS-SymptomDAS28
SF-36
Physical component score
Physical functioning
Role limitation due to physical problems
Bodily pain
Social functioning
Mental component score
Mental health
Role limitation due to emotional problems
Energy and vitality
General health
HAQ
AIMS2
Physical functioning
Affect
Symptom
DAS28
VAS dominant side
VAS left
VAS right
Grip strength left
Grip strength right
–0.70
–0.67
–0.44
–0.68
–0.63
–0.27
–0.37
–0.35
–0.47
–0.53
0.88
-0.73
–0.75
-0.44
–0.61
–0.57
–0.17
–0.29
–0.28
–0.41
–0.49
—
–0.67
–0.64
–0.47
–0.60
–0.59
–0.22
–0.33
–0.28
–0.44
–0.49
0.84
–0.41
–0.33
–0.36
-0.58
–0.69
–0.63
–0.67
–0.48
–0.63
–0.61
0.48
–0.62
–0.46
–0.46
–0.82
–0.67
–0.35
–0.36
–0.45
–0.39
–0.54
0.61
–0.46
–0.36
–0.32
–0.47
–0.39
–0.13
–0.13
–0.26
–0.26
–0.37
0.46
0.85
0.55
0.67
0.42
0.61
0.65
0.60
–0.49
–0.41
0.84
0.48
0.61
0.46
0.49
0.50
0.52
–0.53
–0.43
—
—
—
0.36
0.52
0.52
0.51
–0.36
–0.30
—
—
—
0.32
0.54
0.52
0.48
–0.22
–0.08
—
—
—
0.57
0.65
0.63
0.67
–0.36
–0.30
0.36
0.32
0.57
—
0.46
0.36
0.50
–0.50
–0.37
For all correlation coefficients p < 0.01.
Table 3. Correlation of components of the DAS28 with the DASH.
Componentr
Number of tender joints, upper extremity
CRP
Number of swollen joints, upper extremity
VASDAS
0.38*
0.08†
0.07†
0.48*
* p < 0.01; †Not significant.
Table 4. Comparisons of DASH to SF-36 and DASH to HAQ correlations with other studies.
This Study SooHoo30
Offenbacher7
SF-36
Physical component score
Physical functioning
Role limitation due to physical problems (RP)
Bodily pain
Social functioning
Mental component score
Mental health
Role limitation due to emotional problems (RE)
Energy and vitality
General health
HAQ
–0.70
–0.67
–0.44
–0.68
–0.63
–0.27
–0.37
–0.35
–0.47
–0.53
0.88
–0.50
–0.59
–0.61
–0.43
–0.57
–0.59
–0.55
–0.62
–0.48
–0.36
–0.58
–0.58
–0.79
–0.26
–0.19
–0.21
–0.46
–0.35
0.88

Page 5

The responsiveness of the DASH to treatment was not
formally tested in our study. However, the small 95% CI of
the Bland-Altman coefficient of reliability suggests that
responsiveness is likely to be good. Other studies10have
indeed shown that the DASH can detect and differentiate
changes in disability over time after surgery in patients with
upper extremity musculoskeletal disorders. A 10-point dif-
ference in mean DASH score might be considered as a min-
imal important change10. However, these are outcomes in
unilateral upper extremity disorders, and as noted, RA
patients experience more bilateral upper extremity problems.
Alimitation of our study is that we did not ask the patient
at the time of the retest whether the signs and symptoms of
the disease had changed. However, we did not expect
marked changes because the DASH considers the com-
plaints of the past week.
Our data indicate that the DASH is a valid instrument for
assessing upper extremity complaints in patients with RA.
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Raven, et al: Validity and reliability of DASH