The Disabilities of the Arm, Shoulder, and Hand questionnaire in intercollegiate athletes: Validity limited by ceiling effect

doi:10.1016/j.jse.2009.11.006

Journal of Shoulder and Elbow Surgery

Volume 19, Issue 3, April 2010, Pages 349-354

https://doi.org/10.1016/j.jse.2009.11.006 Get rights and content

Hypothesis

The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire has been validated as an effective upper extremity specific outcome measure. Normative scores have not been established for young athletes. This study was conducted to establish normative DASH scores for intercollegiate athletes. We hypothesized that DASH scores in intercollegiate athletes differ from published values obtained from the general population.

Materials and methods

The DASH questionnaire was administered to 321 athletes cleared for full participation in intercollegiate sports. Their scores were compared with normative values in the general population and 2 other age-matched cohorts.

Results

Intercollegiate athletes had significantly better upper extremity function compared with the general population (1.37 ± 2.96 vs 10.10 ± 14.68, P < .001) and an age-matched cohort of employed adults (1.37 ± 2.96 vs 5.40 ± 7.57, P < .0001). The DASH was 0 for 65.1%. Within this cohort, men reported better upper extremity function than women (0.98 vs 1.82, P = .010). Athletes participating in overhead sports reported worse upper extremity function than nonoverhead athletes (1.81 vs 0.98, P = .042).

Discussion

We report normative DASH values for a group of intercollegiate athletes and show a significant difference between the scores of these athletes and the general population. Within our cohort of competitive athletes, overhead sports and female gender are associated with significantly lower DASH scores and sports module scores. The utility of using these results are limited by a substantial ceiling effect in this population of competitive athletes. Differences within our cohort and differences between our cohort and other populations are minimized by this ceiling effect. Various upper extremity outcome measures may be similarly limited by a ceiling effect and should be examined for appropriateness before use.

Conclusion

Intercollegiate athletes report significantly greater upper extremity function than the general population; however, validity of the DASH in these athletes is limited and population differences may be minimized by a substantial ceiling effect.

Section snippets

Methods

The University of Pennsylvania Institutional Review Board approved this study (Protocol No. 806026).

Results

Data from 321 athletes were analyzed, with demographic data summarized in Table I. Gender, primary sport, and history of upper extremity injury data were available for all patients. The study included 5 athletes who were missing age data. The optional sports module was completed by 252 of the 321 athletes. The mean age was 19.4 years (range, 17.6-22.6 years), 172 were (53.6%) were men, and 82 (25.5%) reported a prior an upper extremity injury. There were 183 Division I and 138 Division II

Discussion

Patient-reported functional outcome metrics are important in evaluating baseline impairment and treatment effectiveness. Global health outcome measures such as the Medical Outcomes Study Short Form have been used to evaluate general health and overall function, whereas more specific measures such as the DASH were developed to be more responsive to specific changes in upper extremity function and to facilitate comparison among different upper extremity conditions.

Like all outcome measures, the

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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A patient-reported outcomes measure (PROM) is responsive if it is sensitive to clinical status changes. The minimal clinically important difference (MCID) is used to indicate meaningful change, helpful in designing studies and adding context to some study results, and is related to instrument responsiveness. Our purpose was to provide MCID estimates for the brief Michigan Hand Outcomes Questionnaire (bMHQ) and Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) in a hand and upper extremity surgery cohort within the context of varying patient-reported mental health.
Data were analyzed from 1,262 adult patients who received surgical care at a single center between January 1, 2018, and December 31, 2019. Patients completed PROMIS PI, PROMIS Global Health (including global mental health [GMH] component), bMHQ, and a pain-focused anchor question before each clinic visit. Data were collected 8 ± 2 weeks before and after surgery. A distribution-based MCID then was calculated for the general patient population, lowest 10th percentile of GMH scores, and top 10th percentile of GMH scores.
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Analysis of subgroups stratified by preoperative patient-reported mental health condition found that preoperative mental health status, as indicated by GMH score, does not have a meaningful impact on responsiveness of bMHQ or PROMIS PI.
A patient’s reported mental health condition does not meaningfully change how these common PRO instruments reflect the patient condition after hand and upper extremity surgery.
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The physical demands of sports can place patients at elevated risk of use-related pathologies, including thoracic outlet syndrome (TOS). Overhead athletes in particular (eg, baseball and football players, swimmers, divers, and weightlifters) often subject their subclavian vessels and brachial plexuses to repetitive trauma, resulting in venous effort thrombosis, arterial occlusions, brachial plexopathy, and more. This patient population is at higher risk for Paget-Schroetter syndrome, or effort thrombosis, although neurogenic TOS (nTOS) is still the predominant form of the disease among all groups. First-rib resection is almost always recommended for vascular TOS in a young, active population, although a surgical benefit for patients with nTOS is less clear. Practitioners specializing in upper extremity disorders should take care to differentiate TOS from other repetitive use–related disorders, including shoulder orthopedic injuries and nerve entrapments at other areas of the neck and arm, as TOS is usually a diagnosis of exclusion. For nTOS, physical therapy is a cornerstone of diagnosis, along with response to injections. Most patients first undergo some period of nonoperative management with intense physical therapy and training before proceeding with rib resection. It is particularly essential for ensuring that athletes can return to their baselines of flexibility, strength, and stamina in the upper extremity. Botulinum toxin and lidocaine injections in the anterior scalene muscle might predict which patients will likely benefit from first-rib resection. Athletes are usually satisfied with their decisions to undergo first-rib resection, although the risk of rare but potentially career- or life-threatening complications, such as brachial plexus injury or subclavian vessel injury, must be considered. Frequently, they are able to return to the same or a higher level of play after full recovery.
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Expert consensus was achieved on a combination of tests utilized within an UE RTS algorithm: 1. Tissue healing time frame is an important consideration in RTS decision making; 2. Patient reported outcome measures should be utilized specifically, DASH and NPRS 3. Strength is measured by handheld dynamometer and is an important consideration. 4. ROM should be utilized and is an important consideration. 5. Physical performance tests utilized include: Closed Kinetic Chain Upper Extremity Stability test, Seated shot-put test and lower extremity/core tests.
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The Responsiveness of the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function in Patients With Cubital Tunnel Syndrome
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The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) and PROMIS Physical Function (PF) are increasingly referenced patient-reported outcomes. To interpret treatment effects with these patient-reported outcomes, investigators must understand magnitudes of change that represent clinically relevant improvement. This study assessed the responsiveness of PROMIS UE and PF in patients with cubital tunnel syndrome.
A retrospective analysis of PROMIS UE and PROMIS PF computer adaptive test scores was performed for patients treated nonoperatively for cubital tunnel syndrome over 3 years at a tertiary institution. The Patient-Reported Outcomes Measurement Information System UE and PROMIS PF outcome scores were collected at initial and return clinic visits. At follow-up appointments, patients completed clinical anchor questions evaluating their degree of interval clinical improvement. Anchor questions allowed categorization of patients into groups that had experienced “no change,” “minimal change,” and “much change.” Minimal clinically important difference (MCID) values were calculated for the PROMIS assessments with anchor-based and distribution-based methods.
A total of 304 patients with PROMIS PF scores and 111 with PROMIS UE scores were analyzed. The MCID for the PROMIS UE was 3.1 (95% confidence interval, 1.4–4.8) using the anchor-based method and 3.7 (95% confidence interval, 2.9–4.4) using the distribution-based method. These point estimates exceeded the minimal detectable change of 2.3. The MCID for the PROMIS PF was unable to be determined in this patient sample because patients reporting mild change did not have score changes exceeding measurement error.
The PROMIS UE v2.0 computer adaptive test detected minimal change in patients managed nonoperatively for cubital tunnel syndrome with an estimated MCID range of 3.1–3.7. While PROMIS PF has demonstrated acceptable performance in patients with a variety of upper extremity conditions, for cubital tunnel syndrome, it was less able to detect subtle change. PROMIS UE appears more responsive to subtle changes in cubital tunnel syndrome symptoms.
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Content validity of the disability of the arm, shoulder, and hand questionnaire in a college-age patient population
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The Disability of the Arm, Shoulder, and Hand questionnaire (DASH) is a region-specific Patient Reported Outcome Measure and has been found to be valid and reliable. However, it has not been evaluated in a young patient population. Our objective was to understand how often the uninjured ‘collegiate’ population completes the specific tasks on the DASH.
A questionnaire-based survey.
A total of 256 participants (age: 19.44 ± 1.83) completed the study. Participants were asked to track how often they completed 21 tasks taken from the DASH over a 14-day period. Data were analyzed using descriptive statistics and A Rasch partial-credit model.
The 3 most commonly completed tasks are Recreational Activities in which you take some force or impact through your arm, shoulder, or hand (e.g., golf, hammering, tennis, etc.), Wash or blow-dry your hair, and Put on a pullover sweater while the least most commonly completed tasks were garden or do yard work, change a light bulb overhead, and sexual activities. Infit statistics ranged from .94 to 1.12, and Outfit ranged from .27 to 1.33. Person and item separation indices were 0.40 and 5.24, respectively. Person and item reliability indices were 0.14 and 0.96, respectively.
Findings from this study suggest that clinicians should be cautious when using the DASH with the ‘college aged’ patient population.

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Outcome StudyThe Disabilities of the Arm, Shoulder, and Hand questionnaire in intercollegiate athletes: Validity limited by ceiling effect

Hypothesis

Materials and methods

Results

Discussion

Conclusion

Section snippets

Methods

Results

Discussion

Disclaimer

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Clin Sports Med

Joint Bone Spine

Ann Readapt Med Phys

Appl Ergon

Prim Care

J Shoulder Elbow Surg

J Hand Surg [Am]

J Clin Epidemiol

Evaluation of a treatment protocol in distal radius fractures: a prospective study in 581 patients using DASH as outcome

Acta Orthop

Rigorous statistical reliability, validity, and responsiveness testing of the Cincinnati knee rating system in 350 subjects with uninjured, injured, or anterior cruciate ligament-reconstructed knees

Am J Sports Med

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

J Hand Ther

Selecting outcome measures in sports medicine: a guide for practitioners using the example of anterior cruciate ligament rehabilitation

Br J Sports Med

Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature

Ann Rheum Dis

Does the disabilities of the arm, shoulder and hand (DASH) scoring system only measure disability due to injuries to the upper limb?

J Bone Joint Surg Br

Outcome Study
The Disabilities of the Arm, Shoulder, and Hand questionnaire in intercollegiate athletes: Validity limited by ceiling effect