Clinically meaningful improvement in disabilities of arm,shoulder, and hand (DASH) following cervical spine surgery

BACKGROUND CONTEXTPatients with cervical spine disease suffer from upper limb disability. At present, no clinical benchmarks exist for clinically meaningful change in the upper limb function following cervical spine surgery.PURPOSEPrimary: to establish clinically meaningful metrics; the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) of upper limb functional improvement in patients following cervical spine surgery. Secondary: to identify the prognostic factors of MCID and SCB of upper limb function following cervical spine surgery.STUDY DESIGNRetrospective cohort study.PATIENT SAMPLEAdult patients ≥18 years of age who underwent cervical spine surgery from 2012 to 2016.OUTCOME MEASURESPatient-reported outcomes: Neck disability index (NDI) and Disabilities of Arm, Shoulder, and Hand (DASH).METHODSMCID was defined as minimal improvement and SCB as substantial improvement in the DASH score at last follow-up. The anchor-based methods (ROC analyses) defined optimal MCID and SCB thresholds with area under curve (AUC) in discriminating improved vs. non-improved patients. The MCID was also calculated by distribution-based methods: half standard-deviation (0.5-SD) and standard error of the mean (SEM) method. A multivariable logistic regression evaluated the impact of baseline factors in achieving the MCID and SCB in DASH following cervical spine surgery.RESULTSBetween 2012 and 2016, 1,046 patients with average age of 57±11.3 years, 53% males, underwent cervical spine surgery. Using the ROC analysis, the threshold for MCID was –8 points with AUC of 0.73 (95% CI: 0.67–0.79) and the SCB was –18 points with AUC of 0.88 (95% confidence interval [CI]: 0.85–0.91). The MCID was –11 points by 0.5–SD and –12 points by SEM-method. On multivariable analysis, patients with myelopathy had lower odds of achieving MCID and SCB, whereas older patients and those with ≥6 months duration of symptoms had lower odds of achieving DASH MCID and SCB respectively.CONCLUSIONsIn patients undergoing cervical spine surgery, MCID of –8 points and SCB of –18 points in DASH improvement may be considered clinically significant. These metrics may enable evaluation of minimal and substantial improvement in the upper extremity function following cervical spine surgery.     

The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: Reliability and validity of the Swedish version evaluated in 176 patients

The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered regionspecific outcome instrument developed to measure upperextremity disability and symptoms. The DASH consists mainly of a 30-item disability/symptom scale. We performed cross-cultural adaptation of the DASH to Swedish, using a process that included double forward and backward translations, expert and lay review, as well as field-testing to achieve linguistic and conceptual equivalence. The Swedish version's reliability and validity were then evaluated in 176 patients with upper-extremity conditions. The patients completed the DASH and SF-12 generic health questionnaire before elective surgery or physical therapy. Internal consistency of the DASH was high (Cronbach alpha 0.96). Test-retest reliability, evaluated in a subgroup of 67 patients who completed the DASH on two occasions, with a median interval of 7 days, was excellent (intraclass correlation coefficient 0.92). Construct validity was shown by a positive correlation of DASH scores with the SF-12 scores (worse upper-extremity disability correlating with worse general health), stronger correlation with the SF-12 physical than with the mental health component, correlation of worse DASH scores with worse self-rated global health, and ability to discriminate among conditions known to differ in severity. The Swedish version of the DASH is a reliable and valid instrument that can provide a standardized measure of patient-centered outcomes in upper-extremity musculoskeletal conditions.     

The disabilities of the arm,shoulder and hand (DASH) outcome questionnaire: Reliability and validity of the Swedish version evaluated in 176 patients

The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered regionspecific outcome instrument developed to measure upperextremity disability and symptoms. The DASH consists mainly of a 30-item disability/symptom scale. We performed cross-cultural adaptation of the DASH to Swedish, using a process that included double forward and backward translations, expert and lay review, as well as field-testing to achieve linguistic and conceptual equivalence. The Swedish version's reliability and validity were then evaluated in 176 patients with upper-extremity conditions. The patients completed the DASH and SF-12 generic health questionnaire before elective surgery or physical therapy. Internal consistency of the DASH was high (Cronbach alpha 0.96). Test-retest reliability, evaluated in a subgroup of 67 patients who completed the DASH on two occasions, with a median interval of 7 days, was excellent (intraclass correlation coefficient 0.92). Construct validity was shown by a positive correlation of DASH scores with the SF-12 scores (worse upper-extremity disability correlating with worse general health), stronger correlation with the SF-12 physical than with the mental health component, correlation of worse DASH scores with worse self-rated global health, and ability to discriminate among conditions known to differ in severity. The Swedish version of the DASH is a reliable and valid instrument that can provide a standardized measure of patient-centered outcomes in upper-extremity musculoskeletal conditions.     

The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: reliability and validity of the Swedish version evaluated in 176 patients

The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered region-specific outcome instrument developed to measure upper-extremity disability and symptoms. The DASH consists mainly of a 30-item disability/symptom scale. We performed cross-cultural adaptation of the DASH to Swedish, using a process that included double forward and backward translations, expert and lay review, as well as field-testing to achieve linguistic and conceptual equivalence. The Swedish version's reliability and validity were then evaluated in 176 patients with upper-extremity conditions. The patients completed the DASH and SF-12 generic health questionnaire before elective surgery or physical therapy. Internal consistency of the DASH was high (Cronbach alpha 0.96). Test-retest reliability, evaluated in a subgroup of 67 patients who completed the DASH on two occasions, with a median interval of 7 days, was excellent (intraclass correlation coefficient 0.92). Construct validity was shown by a positive correlation of DASH scores with the SF-12 scores (worse upper-extremity disability correlating with worse general health), stronger correlation with the SF-12 physical than with the mental health component, correlation of worse DASH scores with worse self-rated global health, and ability to discriminate among conditions known to differ in severity. The Swedish version of the DASH is a reliable and valid instrument that can provide a standardized measure of patient-centered outcomes in upper-extremity musculoskeletal conditions.     

Responsiveness of the disability of the arm, shoulder, and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) in evaluating change after hand therapy.

A hand therapy clinic used a systematic process to select an outcome tool for routine use. After a literature review of available instruments, the choice had been narrowed to two instruments: the Disability of the Arm, Shoulder, and Hand (DASH) and the Patient-Rated Wrist Evaluation (PWRE). The PRWE was modified to attribute to the hand/wrist. A cohort of 60 patients (36 hand problems, 24 wrist problems) completed a DASH and PRWHE at their initial clinic visit and three months later. Standardized response means (SRMs) and effect sizes indicated a large treatment effect. The PRWHE had slightly higher responsiveness than the DASH (SRM=1.51 vs. 1.37). Because this level of responsiveness was obtained with fewer items, it was considered more efficient. A supplementary esthetics question was less responsive than either scale, but was thought to be an important option for selected patients. On completion of the trial period, the therapists unanimously selected the PRWHE with a supplemental esthetics question to be routinely used in measurement of outcomes.     

Disabilities of the arm, shoulder and hand (DASH) questionnaire: Determining functional activity profiles in patients with upper extremity disorders

The Disability of Arm, Shoulder and Hand (DASH) questionnaire is a standardized measure which captures the patients' own perspective of their upper extremity health status. Based on the scores of the DASH modules: symptoms, function and sport, this follow-up study of 590 hand-injured subjects from 11 diagnostic groups evaluated impairments and disabilities perceived 2 to 5 years postoperatively. Secondly, we explored the relationships between the diagnostic groups at the individual DASH item level. Exploratory testing of statistical significance showed that the DASH modules differentiated well among the groups (ANOVA P-value 0.001) and further differences existed at the item level, so that functional activity problem profiles could be developed for each diagnostic group. Our findings confirm that the DASH is a useful instrument for outcome evaluation. Moreover, in view of the continuing challenge to provide comprehensive care which meets patients' needs in the shortest space of time, we consider that DASH has potential in the development of patient-centred treatment programmes which are tailored to the individual patients' requirements and have relevance to their daily activities.     

The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH

Background  

The 30-item disabilities of the arm, shoulder and hand (DASH) questionnaire is increasingly used in clinical research involving upper extremity musculoskeletal disorders. From the original DASH a shorter version, the 11-item QuickDASH, has been developed. Little is known about the discriminant ability of score changes for the QuickDASH compared to the DASH. The aim of this study was to assess the performance of the QuickDASH and its cross-sectional and longitudinal validity and reliability.     

The disabilities of the arm,shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery

Background

The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered region-specific outcome instrument developed as a measure of self-rated upper-extremity disability and symptoms. The DASH consists mainly of a 30-item disability/symptom scale, scored 0 (no disability) to 100. The main purpose of this study was to assess the longitudinal construct validity of the DASH among patients undergoing surgery. The second purpose was to quantify self-rated treatment effectiveness after surgery.

Methods

The longitudinal construct validity of the DASH was evaluated in 109 patients having surgical treatment for a variety of upper-extremity conditions, by assessing preoperative-to-postoperative (6–21 months) change in DASH score and calculating the effect size and standardized response mean. The magnitude of score change was also analyzed in relation to patients' responses to an item regarding self-perceived change in the status of the arm after surgery. Performance of the DASH as a measure of treatment effectiveness was assessed after surgery for subacromial impingement and carpal tunnel syndrome by calculating the effect size and standardized response mean.

Results

Among the 109 patients, the mean (SD) DASH score preoperatively was 35 (22) and postoperatively 24 (23) and the mean score change was 15 (13). The effect size was 0.7 and the standardized response mean 1.2.The mean change (95% confidence interval) in DASH score for the patients reporting the status of the arm as "much better" or "much worse" after surgery was 19 (15–23) and for those reporting it as "somewhat better" or "somewhat worse" was 10 (7–14) (p = 0.01). In measuring effectiveness of arthroscopic acromioplasty the effect size was 0.9 and standardized response mean 0.5; for carpal tunnel surgery the effect size was 0.7 and standardized response mean 1.0.

Conclusion

The DASH can detect and differentiate small and large changes of disability over time after surgery in patients with upper-extremity musculoskeletal disorders. A 10-point difference in mean DASH score may be considered as a minimal important change. The DASH can show treatment effectiveness after surgery for subacromial impingement and carpal tunnel syndrome. The effect size and standardized response mean may yield substantially differing results.

     

The value of remembered pre-operative quick disabilities of the arm,shoulder and hand (QuickDASH) scores

Abstract

It would be useful if it were possible for the patients to recreate their pre-operative QuickDASH scores in audits where this score had not been recorded before surgery. We assessed the accuracy of remembered pre-operative QuickDASH scores among 229 consecutive patients and the value of a previously developed algorithm for correcting these scores. Real pre-operative scores and remembered pre-operative scores were compared after a mean of 21?months. Furthermore, the scores of a subgroup of 79 patients with carpal tunnel syndrome, subacromial impingement, thumb basal joint arthrosis or Dupuytren’s contracture were corrected using an algorithm. The mean difference between remembered and real pre-operative scores for all patients showed heteroscedacity in the Bland–Altman plot. The scores of the 79 sub-analysis patients were homoscedastic. The mean difference between remembered and real pre-operative scores was 9 (SD 16, SEM 1.85). Correcting the scores of the sub-group patients using our algorithm decreased the variation only moderately. The remembered pre-operative score is too inaccurate to be useful in individual patients, also when using our algorithm. However, subtracting nine from the mean remembered pre-operative score in a group of patients with any of the above diagnoses gives the real pre-operative score within the 95% confidence interval of four above and four below the real score.     

Cross-cultural adaptation and clinical evaluation of a Korean version of the disabilities of arm, shoulder, and hand outcome questionnaire (K-DASH)

We developed a Korean version of the disabilities of arm, shoulder, and hand outcome questionnaire (K-DASH) by performing cross-cultural adaptation and evaluated the reliability and validity of the K-DASH. The K-DASH, SF-36, and Visual Analog Scale (VAS) for pain were administered to 161 patients with arm, shoulder, and hand problems. The internal consistency of the disability/symptom scores of the K-DASH was high (Cronbach's alpha 0.94). The retest assessed 131 of the 161 patients. The intraclass correlation coefficient was 0.91. The construct validity was evaluated using the correlations between the K-DASH and the SF-36 and VAS. The physical and mental component summary scales of the SF-36 and the VAS at rest and during activity were significantly correlated with the DASH disability/symptom scores. Despite the linguistic and cultural differences, the reliability and validity of the K-DASH were just as excellent as those of the original DASH.     

Construct validity of the Chinese version of the disabilities of the arm, shoulder and hand questionnaire (DASH-HKPWH)

The study evaluated the construct validity of the Chinese Hong Kong version of the disabilities of the arm, shoulder and hand questionnaire (DASH-HKPWH). Three hundred and thirty four patients with a broad range of upper extremity disorders were recruited into the study. Each completed DASH-HKPWH and SF-36 forms and their pain intensity (numeric pain rating scale) and grip strength were also measured. The mean DASH-HKPWH score was 40 (SD=20). Principal component factor analysis identified a single factor, which accounted for 47% of the total variance. Pearson correlation was applied to assess convergent and divergent validity of the DASH-HKPWH by comparison with the above-mentioned subjective and objective measurements. Our findings were comparable to the DASH of other languages.     

Reliability and validity of the Danish version of the disabilities of arm, shoulder, and hand questionnaire in patients with fractured wrists

The disabilities of arm, shoulder, and hand (DASH) questionnaire is a 30-item region-specific questionnaire that is used to measure the effect of treatment of the upper extremity. The purpose of this study was to assess the reliability of, and validate, the Danish version of the DASH score in patients with fractured wrists. Sixty patients were studied. We investigated internal consistency and test-retest reliability, convergent validity, content validity and responsiveness. Time to complete questionnaire was 11 minutes and two questionnaires were not usable. The internal consistency was sufficient (Cronbach's alpha 0.96 and intraclass correlation coefficient 0.89). The difference in the mean was 4.6 (CI: 0.48 to 8.72, p = 0.03). Convergent validity at first and last control was high for both pain, 0.46 and 0.40 respectively, and for physical mobility, 0.64 and 0.65 respectively, indicating that results confirmed other similar scores. We conclude that the Danish version of the 30-item DASH questionnaire is valid and practical for patients with fractured wrists.     

Comparison of health state utility measures and disabilities of arm,shoulder and hand questionnaire scores in bilateral hand amputees

Bilateral hand amputation (BHA) is a life-changing event that can result in a great degree of loss of function. Prosthetic limb replacement and composite tissue allotransplantation are the treatment options. Understanding the BHA in terms of economic utility will help direct future research and upgrading in healthcare delivery. This is a cross-sectional study in 32 BHA who have completed a minimum of six months after wound healing. The primary objective was to assess the convergent validity of three different health utility (HU) derivation methods, namely the time trade-off (TTO), EuroQol questionnaire (EQ-5D-5L), and EuroQol visual analog scale (EQ-VAS) among BHA. The secondary objective was to correlate the disabilities of arm, shoulder and hand (DASH) scores with the HU scores and see whether the DASH score predicts the HU scores derived by different methods. The mean (SD) HU scores for TTO, VAS, and EQ-5D-5L were 0.34 (0.25), 0.61 (0.25), and 0.46 (0.20), respectively. HU derived by the TTO method displayed a weak correlation with EuroQol-based derivatives (EQ-VAS & EQ-5D-5L). But there was a moderate correlation between values by EQ-VAS & EQ-5D-5L. Hence, the EuroQol HU derivative is preferable to TTO. The mean (SD) of the DASH score was 48.4 (22.9). There was a strong correlation between the DASH scores and HU derived by different methods. Also, the DASH score is seen to be a good predictor of HU scores. This study is the first to derive HU and correlate the DASH with HU scores in the BHA scenario .     

Comparison of therapeutic activities with therapeutic exercises in the rehabilitation of young adult patients with hand injuries

PURPOSE: To compare the efficacy of therapeutic activities that mimick the activities of daily living with that of traditionally used therapeutic exercises in the management of injured hands in young adult patients. METHODS: Thirty-six patients having functional loss due to hand injury were enrolled. Patients were allocated randomly into 2 groups. The study group included 20 patients, and the control group included 16 patients. For the control group, according to their impairments, an exercise program including passive, active assistive, and active range of motion and strengthening exercises in addition to physical modalities was applied for 2 sessions a day. For the study group, in addition to 1 session of the same program, a program composed of 25 activities that mimick activities of daily living (ADL) was applied for 1 session. Treatment continued for 3 weeks, 5 days a week. Then the patients were given a home program. After 2 months, patients were reevaluated. RESULTS: Mean age for the patients was 23 years +/- 3. The time span from injury to surgery was a mean of 7 days +/- 5, and the mean period between the injury and the physical therapy was a mean of 102 days +/- 68. Grip strength, pinch strength, finger pulp-distal palmar crease distance, total active movement, range of opposition, range of abduction, Jebsen hand function test, and Disabilities of Arm, Shoulder, and Hand scores were obtained before treatment, after treatment, and 2 months after treatment. At final assessment, differences in improvements of all parameters were found to be statistically significant between the groups in favor of the study group. CONCLUSIONS: Because of the complex anatomy, determination of the most appropriate treatment may not be easy in an injured hand. Our results showed that the therapeutic activities that mimick the ADL improve the functions of the hand more effectively. We suggest that the therapeutic activities that mimick the ADL may be more beneficial than the standard rehabilitation activities in the management of an injured hand.     

Training with a mirror in rehabilitation of the hand

Treatment with a mirror gives an illusion of function in a missing or non-functioning hand. The method is based on the concept that the central representation of phantoms and body image can change rapidly, and has been described in the treatment of phantom pain and stroke. We show in three pilot cases new applications for the use of the mirror in rehabilitation after hand surgery.