Suggestions for Refinement of the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH): A Factor Analysis and Rasch Validation Study


      Franchignoni F, Giordano A, Sartorio F, Vercelli S, Pascariello B, Ferriero G. Suggestions for refinement of the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH): a factor analysis and Rasch validation study.


      To perform a comprehensive psychometric analysis of Disabilities of the Arm, Shoulder and Hand (DASH) to examine its properties and provide insights for an improved version.


      Methodologic research on cross-sectional data from a convenience sample.


      A free-standing rehabilitation center.


      Outpatients and inpatients (N=238; 56% men; mean age, 52.2y) with upper-extremity musculoskeletal disorders.

      Main Outcome Measure

      The official Italian version of DASH was analyzed by factor (both explorative and confirmatory) and Rasch analysis for evaluating dimensionality, functioning of rating scale categories, item fit, hierarchy of item difficulties, and reliability indices.


      Not applicable.


      Factor analysis established the presence of 3 underlying constructs related to manual functioning (items 1–5, 7–11, 16–18, 20, 21), shoulder range of motion (items 6, 12–15, 19), and symptoms and consequences (items 22–30). Rating scale diagnostics showed category malfunctioning. The fit to the Rasch model was good for all items except 4 (items 20, 21, 25, 26). Ten item pairs had high residual correlations after subtraction of the Rasch dimension (local dependency). A test model based on the 3 subscales suggested by factor analysis and corrected categories still showed misfitting in items 21 (“Sexual Activities”) and 26 (“Tingling”) and the presence of some dependent items.


      Unidimensionality and the key domains identified by the original developers as the theoretic framework of DASH were not confirmed by our analyses. The response categories showed misfunctioning. “Sexual Activities” and “Tingling” misfit the Rasch model. Further detailed investigations of DASH are warranted, both to confirm these results in different health conditions and cultures, and to reanalyze in-depth content validity issues regarding the questionnaire.

      Key Words

      List of Abbreviations:

      CFA (confirmatory factor analysis), CFI (Comparative Fit Index), DASH (Disabilities of the Arm, Shoulder and Hand), EFA (exploratory factor analysis), IRT (item response theory), MnSq (mean-square statistics), RA (Rasch analysis), RMSEA (root mean square error of approximation), SRMR (standardized root mean square residual), TLI (Tucker-Lewis Index)
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        • Hudak P.L.
        • Amadio P.C.
        • Bombardier C.
        Development of an upper extremity outcome measure: the DASH.
        Am J Ind Med. 1996; 29: 602-608
        • Beaton D.E.
        • Katz J.N.
        • Fossel A.H.
        • Wright J.G.
        • Tarasuk V.
        • Bombardier C.
        Measuring the whole or the parts?.
        J Hand Ther. 2001; 14: 128-146
        • Roy J.S.
        • MacDermid J.C.
        • Woodhouse L.J.
        Measuring shoulder function: a systematic review of four questionnaires.
        Arthritis Rheum. 2009; 61: 623-632
        • Bot S.D.
        • Terwee C.B.
        • van der Windt D.A.
        • Bouter L.M.
        • Dekker J.
        • de Vet H.C.
        Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature.
        Ann Rheum Dis. 2004; 63: 335-341
        • Atroshi I.
        • Gummesson C.
        • Andersson B.
        • Dahlgren E.
        • Johansson A.
        The DASH outcome questionnaire: reliability and validity of the Swedish version evaluated in 176 patients.
        Acta Orthop Scand. 2000; 71: 613-618
        • Veehof M.M.
        • Sleegers E.J.
        • van Veldhoven N.H.
        • Schuurman A.H.
        • van Meeteren N.L.
        Psychometric qualities of the Dutch language version of the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH-DLV).
        J Hand Ther. 2002; 15: 347-354
        • Padua R.
        • Padua L.
        • Ceccarelli E.
        • et al.
        Italian version of the DASH questionnaire: cross-cultural adaptation and validation.
        J Hand Surg Br. 2003; 28: 179-186
        • Offenbaecher M.
        • Ewert T.
        • Sangha O.
        • Stucki G.
        Validation of a German version of DASH questionnaire (DASH-G).
        J Rheumatol. 2002; 29: 401-402
        • Liang H.W.
        • Wang H.K.
        • Yao G.
        • Horng Y.S.
        • Hou S.M.
        Psychometric evaluation of the Taiwan version of the Disability of the Arm, Shoulder and Hand (DASH) questionnaire.
        J Formos Med Assoc. 2004; 103: 773-779
        • Lee E.W.
        • Chung M.M.
        • Li A.P.
        • Lo S.K.
        Construct validity of the Chinese version of the Disabilities of the Arm, Shoulder and Hand (DASH-HKPWH) questionnaire.
        J Hand Surg Br. 2005; 30: 29-34
        • Hervás M.T.
        • Navarro Collado M.J.
        • Peiró S.
        • Rodrigo Pérez J.L.
        • López Matéu P.
        • Martínez Tello I.
        Version espanola del cuestionario DASH: adaptacion transcultural, fiabilidad, validez y sensibilidad a los cambios.
        Med Clin (Barc). 2006; 127: 441-447
        • Fayad F.
        • Lefevre-Colau M.M.
        • Macé Y.
        • et al.
        Validation of the French version of the Disability of the Arm, Shoulder and Hand questionnaire (F-DASH).
        Joint Bone Spine. 2008; 75: 195-200
        • Cheng H.M.
        • Sampaio R.F.
        • Mancini M.C.
        • Fonseca S.T.
        • Cotta R.M.
        Disabilities of the Arm, Shoulder and Hand (DASH): factor analysis of the version adapted to Portuguese/Brazil.
        Disabil Rehabil. 2008; 30: 1901-1909
        • Mousavi S.J.
        • Parnianpour M.
        • Abedi M.
        • et al.
        Cultural adaptation of the Persian version of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure.
        Clin Rehabil. 2008; 22: 749-757
        • Lee J.Y.
        • Lim J.Y.
        • Oh J.H.
        • Ko Y.M.
        Cross-cultural adaptation and clinical evaluation of a Korean version of the Disabilities of Arm, Shoulder, and Hand outcome questionnaire (K-DASH).
        J Shoulder Elbow Surg. 2008; 17: 570-574
        • Beaton D.E.
        • Wright J.G.
        • Katz J.N.
        • Upper Extremity Collaborative Group
        Development of the QuickDASH: comparison of three item-reduction approaches.
        J Bone Joint Surg Am. 2005; 87: 1038-1046
        • Tesio L.
        Measuring behaviours and perceptions: Rasch analysis as a tool for rehabilitation.
        J Rehabil Med. 2003; 35: 105-115
        • Bond T.G.
        • Fox C.M.
        Applying the Rasch model: fundamental measurement in the human sciences.
        Lawrence Erlbaum Associates, Mahwah2001
        • Conrad K.J.
        • Smith Jr, E.V.
        International conference on objective measurement: applications of Rasch analysis in health care.
        Med Care. 2004; 42: I1-I6
        • Solway S.
        • Beaton D.E.
        • McConnell S.
        • Bombardier C.
        The DASH outcome measure user's manual.
        2nd ed. Institute for Work and Health, Toronto2002
        • Bland J.M.
        • Altman D.G.
        Cronbach's alpha.
        BMJ. 1997; 314: 572
        • Horn J.L.
        A rationale and test for the number of factors in factor analysis.
        Psychometrika. 1965; 30: 179-185
        • Jöreskog K.G.
        Structural equation modeling with ordinal variables using LISREL.
        Scientific Software International, Lincolnwood2005 (Accessed March 29, 2010)
        • Guadagnoli E.
        • Velicer W.F.
        Relation to sample size to the stability of component patterns.
        Psychol Bull. 1988; 103: 265-275
        • Schermelleh-Engel K.
        • Moosbrugger H.
        Evaluating the fit of structural equation models: tests of significance and descriptive goodness-of-fit measures.
        Methods Psychol Res Online. 2003; 8: 23-72
        • Masters G.N.
        A Rasch model for partial credit scoring.
        Psychometrika. 1982; 47: 149-174
        • Linacre J.M.
        Optimizing rating scale category effectiveness.
        J Appl Meas. 2002; 3: 85-106
        • Linacre J.M.
        A user's guide to Winsteps-Ministep: Rasch-model computer programs.
        Program manual 3.68.0., Chicago2009 (Accessed July 29, 2010)
        • Frost M.H.
        • Reeve B.B.
        • Liepa A.M.
        • Stauffer J.W.
        • Hays R.D.
        • Mayo/FDA Patient-Reported Outcomes Consensus Meeting Group
        What is sufficient evidence for the reliability and validity of patient-reported outcome measures?.
        Value Health. 2007; 10: S94-S105
        • Reeve B.B.
        • Hays R.D.
        • Bjorner J.B.
        • et al.
        Psychometric evaluation and calibration of health-related quality of life item banks: plans for the Patient-Reported Outcomes Measurement Information System (PROMIS).
        Med Care. 2007; 45: S22-S31
        • Coste J.
        • Bouée S.
        • Ecosse E.
        • Leplège A.
        • Pouchot J.
        Methodological issues in determining the dimensionality of composite health measures using principal component analysis: case illustration and suggestions for practice.
        Qual Life Res. 2005; 14: 641-654
        • Haley S.M.
        • Coster W.J.
        • Andres P.L.
        • et al.
        Activity outcome measurement for postacute care.
        Med Care. 2004; 42: I49-I61
        • Zwick W.R.
        • Velicer W.F.
        Comparison of five rules for determining the number of components to retain.
        Psychol Bull. 1986; 99: 432-442
        • Khan W.S.
        • Jain R.
        • Dillon B.
        • Clarke L.
        • Fehily M.
        • Ravenscroft M.
        The “M2 DASH”-Manchester-modified Disabilities of Arm Shoulder and Hand score.
        Hand (N Y). 2008; 3: 240-244
        • Dixon D.
        • Johnston M.
        • McQueen M.
        • Court-Brown C.
        The Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) can measure the impairment, activity limitations and participation restriction constructs from the International Classification of Functioning, Disability and Health (ICF).
        BMC Musculoskelet Disord. 2008; 9: 114
        • Wolfe E.W.
        • Smith Jr, E.V.
        Instrument development tools and activities for measure validation using Rasch models: part I—instrument development development tools.
        J Appl Meas. 2007; 8: 97-123
        • Huisstede B.M.
        • Feleus A.
        • Bierma-Zeinstra S.M.
        • Verhaar J.A.
        • Koes B.W.
        Is the Disability of arm, Shoulder, and Hand questionnaire (DASH) also valid and responsive in patients with neck complaints.
        Spine (Phila Pa 1976). 2009; 34: E130-E138
        • Lee E.W.
        • Lau J.S.
        • Chung M.M.
        • Li A.P.
        • Lo S.K.
        Evaluation of the Chinese version of the Disability of the Arm, Shoulder and Hand (DASH-HKPWH): cross-cultural adaptation process, internal consistency and reliability study.
        J Hand Ther. 2004; 17: 417-423
        • Marx R.G.
        • Bombardier C.
        • Hogg-Johnson S.
        • Wright J.G.
        Clinimetric and psychometric strategies for development of a health measurement scale.
        J Clin Epidemiol. 1999; 52: 105-111
        • Alotaibi N.M.
        The cross-cultural adaptation of the Disability of Arm, Shoulder and Hand (DASH): a systematic review.
        Occup Ther Int. 2008; 15: 178-190
        • Wolfe E.W.
        • Smith Jr, E.V.
        Instrument development tools and activities for measure validation using Rasch models: part II—validation activities.
        J Appl Meas. 2007; 8: 204-234