In the early 1990s, there was a growing recognition in the clinical world of the need for patient-reported outcome measures. Clinicians made the case that, not only were these self-reported measures more relevant to patients, research was also showing they correlated better with patients’ functional ability.
Aware of this shift in focus, researchers and clinicians at the American Academy of Orthopedic Surgeons and the Institute for Work & Health decided to develop an instrument that would measure the impact on function of a wide variety of musculoskeletal conditions and injuries affecting the upper limb—the arm, shoulder or hand. The team agreed early on that the tool would measure function and disability among people with any disorder or multiple disorders of the upper limb. Such a tool would have broader clinical application and would also allow researchers to compare symptoms and treatments across different conditions and disorders.
From this collaboration, the DASH (Disabilities of the Arm, Shoulder and Hand) Outcome Measure was published in 1996. The DASH, free to use for non-commercial purposes, is a proprietary 30-item questionnaire that patients complete, scoring their symptoms and disability or physical function together across a variety of activities such as opening a jar, cutting food with a knife or pulling a sweater overhead. An alternative format of the measure—a shorter, 11-item version called the QuickDASH—was released in 2005. And in July 2013, an iPad app version of the DASH Outcome Measure was released, providing real-time administration, scoring and tracking over time, making it easier for clinicians to use the measure and interpret results.
The DASH Outcome Measure has proved to be very popular. In 2013 alone, the DASH website was viewed 344,639 times, with a total of 83,848 unique visitors and an average of 332 visits a day. That same year, there were 17,006 downloads of the QuickDASH and 15,709 downloads of the DASH questionnaires. By the end of 2013, the measure had appeared in 1,577 peer-reviewed journal articles, including 1,281 articles where it was used to measure study outcomes.
The popularity of the DASH extends around the world. As of mid-2014, research groups, university departments and clinical centres had translated the DASH and QuickDASH into 36 languages and 16 dialects. There are now DASH questionnaires available in Arabic, Hindi, Persian, Slovene and Yoruba, just to name a few examples.
How clinicians, health-care providers are using DASH
For clinicians, the DASH has proved a valuable tool in two ways: to describe the disability experienced by people with upper limb disorders, and to monitor changes in symptoms and function over time.
Kenneth Wilson, a certified hand therapist who’s now director of health occupation programs at Jefferson College in Hillsboro, Missouri, says when he was working in the clinical setting, the DASH tool helped him identify which items were difficult for patients. Wilson says this saved him time in the assessment phase, because he could focus directly on items that patients had indicated as difficult.
I then took the high scoring items on the DASH, and those immediately became the functional goals for my patient, he adds.
Dr. Sue Dahl-Popolizio, a clinical assistant professor at Arizona State University and a certified hand therapist with over 20 years of clinical experience, speaks of the value of the DASH in monitoring change over time. She uses it at initial assessment and then at discharge from treatment to track the patient’s progress for insurance reporting.
Insurance companies are saying this is a standardized measure and you need to use this for your patients with upper extremity involvement, says Dahl-Popolizio.
It’s interesting that the insurance company has singled out this one very specialized assessment and is requiring us to use it.
That tracking utility has become even more important to practitioners in the United States as of 2013. Under a new program mandated by federal legislation in 2012, the Centers for Medicare and Medicaid Services (CMS) now requires clinicians treating Medicare patients to submit information regarding patients’ functional limitations, therapy services provided and outcomes achieved on patient function. In response to the new requirement, the American Physical Therapy Association provided members with a list of outcome measures to consider using for each specialty. The DASH Outcome Measure appeared on several lists, including oncology, geriatrics and home health, orthopaedics, and hand rehabilitation specialties.
In Canada, administrative bodies are also requiring clinicians to use the DASH. For example, the Workplace Safety and Insurance Board (WSIB) in Ontario operates a “Program of Care” for workers with shoulder injuries. At two points in the program—initial assessment and discharge—the program requires clinicians to complete, record and submit QuickDASH results to the WSIB. WSIB uses these results to measure the success of the Shoulder Program of Care and of the health professionals delivering the program.
Several studies now describe the application and testing of the DASH and QuickDASH for more than just patients with musculoskeletal disorders. It’s also being used beyond the body regions, types of disorders and age groups for which it was originally developed, including among breast cancer patients. As it approaches its 20th anniversary, the DASH Outcome Measure can accurately be described as a little measure that grew.