DASH for physical therapists
DASH or Disabilities of the Arm, Shoulder and Hand Questionnaire measures conditions and injuries affecting the upper extremity, which can significantly impact an individual's day-to-day life. Considering how many tasks require using one or both hands or arms, it is easy to see how important a physical therapist's role is in evaluating and treating the upper extremity.
Summary
- The DASH questionnaire is a self-report tool that asks patients about their symptoms and daily activity limitations.
- It provides valuable insights into upper extremity function by combining both subjective and objective outcome measures.
- The tool is available in multiple versions and languages, making it versatile for various patient populations and conditions.
- Regular use of the DASH can help therapists track treatment progress, set improvement goals, and justify ongoing care.
Some common upper extremity conditions treated by physical therapists include:
- Arthritis
- Rotator cuff injuries
- Fractures
- Post-stroke arm weakness
- Neurologic conditions affecting the arm
- Carpal tunnel
- Wrist sprains
- Medial and lateral epicondylalgia
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When assessing upper extremity function, you have many tests to choose from. Objective outcome measures administered by you, the therapist, quantify the impairments and activity limitations your patients are experiencing.
Objective outcome measures you might consider when assessing the upper extremity can include:
- Manual muscle testing
- Range of motion measurements
- Palpation
- Limb girth measurements
- Dynamometry
- Fine motor assessments like the 5-hole peg test or box and blocks
While objective measures are vital in patient examination, let's not forget the importance of subjective tests. Subjective outcome measures provide insight into patients' perception of their symptoms, function level, or disability. Because patient perception of the severity or impact of an impairment can differ greatly from your objective assessment, it is always a good idea to include a subjective outcome measure.
One popular option for the upper extremity is the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH). The DASH prompts patients to answer questions about their symptoms and their ability to perform specific activities.
Therapists can track DASH score over time to assess how effective your treatments have been on patient perception of symptoms and activity limitations. The DASH is recommended as a self-reported measure to track shoulder pain and dysfunction in Shoulder Health after SCI: PT Examination, a fact sheet produced by the Spinal Cord Injury Special Interest Group of the Academy of Neurologic Physical Therapy (ANPT).
It is also recommended that students be exposed to it as part of the ANPT's Final EDGE Recommendations. Let's dive deeper into the DASH.
What is the DASH for?
The DASH is both a body-structure function and an activity-level self-report questionnaire. It was jointly developed in 1996 by the Institute for Work & Health and the American Academy of Orthopaedic Surgeons (AAOS). The DASH is free to administer, and copies can be found online. Most often, physical therapists score the DASH by hand. However, clinics can incorporate this outcome measure in an online software platform to allow for electronic submission and grading of the questionnaire.
The only equipment needed is paper and pencil or a computer. If a patient cannot complete the questionnaire independently due to their upper extremity condition, be prepared to assist them.
Most questions ask about activity limitations, but therapists can also address weakness and stiffness.
There are three versions of the DASH.
- The original version contains 30 questions. Questions 1-21 ask about activities ranging from opening a tight jar and washing your back to recreational and sexual activities. The remaining questions ask about pain, stiffness, tingling, and weakness and how these symptoms have interfered with or limited other activities.
- The QuickDash contains 11 items.
- The QuickDash-9 contains only nine items.
Some versions of the DASH also include optional work and sports/performing arts modules. Patients will select the answer they most agree with for each item.
What does the DASH score indicate?
Scoring for all versions of the DASH uses a 5-point Likert scale. For questions about activity limitations, the scoring options are as follows:
- No difficulty
- Mild difficulty
- Moderate difficulty
- Severe Difficulty
- Unable
For items asking about how much symptoms limit or interfere with tasks like work or social activities, the scoring options are as follows:
- Not at all
- Slightly
- Moderately
- Quite a bit
- Extremely
For items asking about severity of symptoms like pain or weakness, the scoring options are as follows:
- None
- Mild
- Moderate
- Severe
- Extreme
A question about sleep difficulty provides the following scoring options:
- No difficulty
- Mild difficulty
- Moderate difficulty
- Severe Difficulty
- So much difficulty that I cannot sleep
Finally, when the statement "I feel less confident, less capable, or less useful" is presented, patients can choose from the following options:
- Strongly disagree
- Disagree
- Neither Agree nor Disagree
- Agree
- Strongly Agree
Therapists can only calculate scores if more than three items are included on the DASH. Similarly, a score cannot be calculated if more than 1 item is missing on the QuickDASH.
Total scores range from 0 (minimum) to 100 (maximum)
Full DASH DISABILITY/SYMPTOM SCORE = [(sum of n responses) - 1] x 25n
N is equal to the number of completed responses.
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Interpreting the scores
Lower scores on the DASH are desirable as they indicate fewer symptoms and better upper extremity function.
Psychometric data is available for many different populations. The Shirley Ryan Ability Lab provides information such as the minimally clinically important difference (MCID), the minimal detectable change (MDC), standard error of measurement, normative data, and others for the following patient populations:
- Arthritis
- Joint pain and fractures
- Musculoskeletal conditions
- Multiple sclerosis
- Non-specific patient population
- Chronic Pain
Selecting the most applicable patient population group when interpreting your patient's scores is best.
Using the DASH to guide client care
Now that you are familiar with the administration of the DASH and know where to look to interpret your score let's review some tips for incorporating the information gleaned from this outcome measure into your plan of care:
- Document the DASH score to help justify the need for skilled physical therapy.
- Use the MCID and MDC to set a goal for improvement in the DASH.
- Re-administer the DASH regularly during progress reassessments to determine the need for continued care and the effectiveness of your treatments so far.
- Rather than just looking at the total score, read over the questionnaire to learn which functional activities are most difficult for the patient, what symptoms are most prominent, and how they affect their life and sleep. Use this information to prioritize your treatments and to ensure that your priorities and treatments are salient to the patient.
As you should now see, the DASH is an easy questionnaire to administer. It is available in 54 languages and dialects, making it easily accessible to many different patients in their native language.
If you have been primarily relying on objective outcome measures to guide your treatment plan for the upper extremity, consider trying the DASH and seeing how beneficial a self-report questionnaire can be to creating an effective and meaningful treatment plan for your patients.
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