J Shoulder Elbow Surg (2010) 19, 349-354
www.elsevier.com/locate/ymse
The Disabilities of the Arm, Shoulder, and Hand
questionnaire in intercollegiate athletes: Validity
limited by ceiling effect
Jason E. Hsu, MDa, Elliot Nacke, MDa, Min J. Park, MD, MMSca, Brian J. Sennett, MDb,
G. Russell Huffman, MD, MPHb,*
a
b
Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia PA
Penn Sports Medicine Center, Philadelphia, PA
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 ¼ .010). Athletes participating in overhead sports reported
worse upper extremity function than nonoverhead athletes (1.81 vs 0.98, P ¼ .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.
Level of evidence: Level IV, Case-Control Study, Diagnostic Study
Ó 2010 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Outcomes research; DASH; upper extremity; normative score; ceiling effect
*Reprint requests: G. Russell Huffman, MD, MPH, Penn Sports Medicine
Center, 235 S. 33rd St, 1st Floor Weightman Hall, Philadelphia, PA 19104.
E-mail address: Russell.Huffman@uphs.upenn.edu (G.R. Huffman).
The American Academy of Orthopedic Surgeons’
(AAOS) Outcomes Research Committee and the Institute
for Work and Health (IWH) constructed the Disabilities of
1058-2746/2010/$36.00 - see front matter Ó 2010 Journal of Shoulder and Elbow Surgery Board of Trustees.
doi:10.1016/j.jse.2009.11.006
350
the Arm, Shoulder, and Hand (DASH) questionnaire in an
attempt to develop an outcome measure that reflects the
effect of upper extremity diseases and injuries on upper
extremity function.15 The AAOS and IWH developed this
tool to allow for comparisons across different upper
extremity conditions and to provide a uniform outcome
measure to evaluate medical treatment and surgical procedures as well as for research purposes.
The DASH questionnaire contains 30 items that are
designed to evaluate symptoms and functional status,
especially physical function, in patients with various upper
extremity musculoskeletal conditions. Each item is rated
on a 5-point Likert scale and includes 21 items that evaluate specific physical activities requiring the arm, shoulder,
or hand (ie, pushing open a door, turning a key, writing,
changing a light bulb overhead), 5 items evaluating symptoms (ie, pain, weakness, stiffness), and 4 questions evaluating limitations of social function, sleep, work, and
self-image. For a score to be calculated, 27 of the 30 items
must be completed. The values for all questions are averaged, and this value is then converted to a 0-100 scale by
subtracting one and multiplying by 25. Higher scores
indicate greater disability. An optional work module and
sports or music module also can evaluate these respective
functions.
The DASH questionnaire has been shown to have good
reliability, responsiveness, and validity in English and other
languages.3,10,13-15,18,27,29 A comparison with joint-specific
questionnaires showed it had validity and responsiveness
for both proximal and distal upper extremity disorders.3
Although the DASH is not a shoulder-specific questionnaire, many systematic reviews have found it has superior
psychometric properties related to shoulder disability
compared with other shoulder-specific outcome measures
such as the American Shoulder and Elbow Surgeons
(ASES) score, the Shoulder Pain and Disability Index
(SPADI), and the Simple Shoulder Test (SST).3,5,24
Establishing normative data through groups of healthy
individuals for an outcome measure such as the DASH
questionnaire is essential because instrument bias may
necessitate stratification of various cohorts for appropriate
comparison.16 Although DASH scores for the general population have been reported,18 studies evaluating normative
DASH values for specific subgroups of patients have been
limited. Previous studies have shown significant variations
dependent on age and gender, as well as for vocational
activity.20,21 The DASH questionnaire has also been validated for a variety of disorders such as rheumatoid arthritis
and injuries such as distal radius fractures.1,12,19,30-32
However, literature regarding the young adult population
has been limited, and normative DASH scores for elite
athletes have not yet been established.
Intercollegiate athletes represent a distinct population in
which normative data based on the general population does
not apply.17 Because most athletes have a high physical
functional level, outcome scores deemed normal for the
J.E. Hsu et al.
general population may in fact be abnormal for an athlete.
Furthermore, ceiling effects in this population may be of
concern, and an athlete may have a normal score on an
outcome scale before reaching full baseline physical
function. Normative scores for global health outcome
measures have been previously reported in athletes, and
other upper extremity outcome measures have been studied
in this group.6,11,25 The DASH scale, however, has yet to be
evaluated in this population. To our knowledge, no published studies have evaluated DASH scores in these intercollegiate athletes. The purpose of this study was to
establish normative data for this specific group that can be
used in subsequent outcome studies in this population. We
hypothesized that DASH scores in intercollegiate athletes
differ from published values obtained from the general
population.
Methods
The University of Pennsylvania Institutional Review Board
approved this study (Protocol No. 806026).
Data collection
National Collegiate Athletic Association (NCAA) Division I and II
college athletes undergoing physical clearance for participation in
sports during the 2007 to 2008 athletic season completed the selfadministered DASH questionnaire. These athletes were participating in 20 sports, including baseball, basketball, cheerleading,
cross-country, fencing, field hockey, football, golf, gymnastics,
lacrosse, rifle, rowing, soccer, softball, squash, swimming/diving,
tennis, track, volleyball, and wrestling. The DASH was administered to each student-athlete during the preparticipation evaluation
before the fall sports season.
In addition to completing the DASH questionnaire, participants
provided demographic information, including date of birth, gender,
primary sport, and history of upper extremity injury. The study
excluded athletes who were not cleared for participation and those
with incomplete DASH data. Of the 342 student-athletes completing
the questionnaire, 321 met the inclusion criteria. Calculation of
prestudy power revealed 190 athletes would need to be included in
the study to detect a 5% difference in DASH scores between athletes
and the general population18 with a certainty of 90% (power 0.9) and
a level of error of 5% (a < 0.05).
Data analysis
DASH data were scored as outlined by the DASH Outcome
Measure User’s Manual.26 Normative DASH data from these
NCAA athletes were compared with previously published
normative values from a sample of 1706 individuals from the
United States (U.S.) general population18 as well as similar agematched cohorts of 206 young, active adults reported by Clarke et
al7 and 226 employed adults reported by Jester et al.20 Sports
module scores were also compared between groups but were not
available for the cohort reported by Clarke et al.7 A 2-sided t test
was used for means testing between subgroups.
The DASH questionnaire in intercollegiate athletes
351
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 athletes.
The 321 NCAA athletes had significantly lower DASH
scores (P < .001) compared with 1706 individuals in U.S.
general population as described by Hunsaker et al18 (1.37 2.96 vs 10.10 14.68, P < .001). A comparison of agematched cohorts found NCAA athletes had a significantly
lower DASH score than employed adults (1.37 2.96 vs
5.40 7.57, P < .0001) and a lower mean DASH score
than young, active adults, although not statistically significant (1.37 2.96 vs. 1.85 5.99, P ¼ .225). Sports
module scores were also significantly lower in NCAA
athletes compared with the general population (1.93 6.24
vs 9.75 22.72, P < .0001) and age-matched employed
adults (1.93 6.24 vs 8.0 18.5, P < .0001). Among the
cohort of 321 athletes, 209 (65.1%) had a DASH score of 0,
another 88 (27.4%) had a score between 0.01 and 5, 17
(5.3%) were between 5.01 and 10, and 6 (1.9%) were
between 10.01 and 20. Only 1 athlete (0.3%) reported
a DASH score above 20 (Fig. 1).
Table II summarizes the DASH scores within our cohort
of athletes. Women had a significantly higher DASH score
than men (1.82 3.27 vs 0.98 2.60, P ¼ .01). Athletes
participating in overhead sports (tennis, baseball, softball,
gymnastics, volleyball, swimming, and squash) reported
significantly worse upper extremity function than other
athletes within the cohort (1.81 3.57 vs 0.98 2.60,
P ¼ .037). There was no significant difference in scores
between athletes with and without a history of any upper
extremity injury (1.30 3.00 vs 1.58 2.83, P ¼ .472).
No differences were documented in overall DASH scores
of Division I and II athletes when accounting for gender
and type of athlete (P > .05).
Table III summarizes the sports module scores in 252 of
the athletes. Significantly higher scores were found in those
that played overhead sports compared with those that
participated in nonoverhead sports (2.88 7.64 vs 1.27 4.94, P ¼ .042). Gender and upper extremity injury did not
significantly affect the sports module scores.
Discussion
Patient-reported functional outcome metrics are important
in evaluating baseline impairment and treatment effectiveness. Global health outcome measures such as the Medical
Figure 1
Distribution of Disabilities of Arm, Shoulder and
Hand (DASH) scores in the National Collegiate Athletic Association (NCAA) athletic cohort.
Table I
Demographic data of the NCAA athletes
Variable
No. or mean (range)
Total participants
Included
Excluded
Age, years
Gender
Male
Female
Prior upper extremity injury
Yes
No
NCAA division
Division I
Division II
342
321
21
19.4 (17.6-22.6)
172
149
82
239
183
138
NCAA, National Collegiate Athletic Association.
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 DASH questionnaire is
subject to significant variations in scores between different
subsets of patients. These variations may be introduced by
factors other than upper extremity pain, disability, or
impairment and therefore underscore the importance of
obtaining normative data for these various cohorts.9 Other
upper extremity outcome measures such as the University
of California Los Angeles (UCLA) Shoulder Score,
Constant score, Western Ontario Outcome Tools, and the
American Shoulder and Elbow Surgeons (ASES) evaluation form have all been studied in athletes.6,25 However, the
DASH questionnaire has not yet been evaluated for
competitive athletes, and normative DASH scores have yet
to be established.
352
Table II
J.E. Hsu et al.
DASH scores for healthy NCAA athletes
DASH score
Variable
No.
Mean (SD)
P
Overall
Gender
Male
Female
Overhead sport
Yes
No
Prior upper extremity injury
Yes
No
321
1.37 (2.96)
172
149
0.98 (2.60)
1.82 (3.27)
.010
121
200
1.81 (3.57)
0.98 (2.60)
.04
82
239
1.30 (3.00)
1.58 (2.83)
.47
DASH, Disabilities of Arm, Shoulder and Hand; NCAA, National Collegiate Athletic Association; SD, standard deviation.
Table III
athletes
DASH sports module scores for healthy NCAA
Sports module score
No.
Overall
Gender
Male
Female
Overhead sport
Yes
No
Prior upper extremity injury
Yes
No
Mean (SD)
P
252 1.93 (6.24)
137 1.69 (5.80)
115 2.23 (6.74)
.49
104 2.88 (7.64)
148 1.27 (4.94)
.04
65 1.91 (6.11)
187 2.02 (6.64)
.9
DASH, Disabilities of Arm, Shoulder and Hand; NCAA, National Collegiate Athletic Association; SD, standard deviation.
Previous studies have shown that intercollegiate athletes
represent a distinct subgroup with normative global health
values different than the general population,17 and our
results support this hypothesis when applied to an upper
extremity-specific outcome measure. This study establishes
normative DASH data for intercollegiate athletes and shows
a statistically significant variation from the general population previously described by Hunsaker et al18 in
a sample of 1706 individuals from the general U.S. population. The data from our intercollegiate athletes were also
compared with age-matched individuals from a population
of working adults in Germany described by Jester et al,20
and our athletes had significantly higher upper extremity
function. NCAA intercollegiate athletes are likely to be
a more motivated, higher-functioning group than both the
general population and the group of employed adults,
resulting in significantly lower DASH scores for young
athletes in this study. Scores in our intercollegiate athletes
were also lower compared with scores in a young, active
adult population described by Clarke et al,7 although this
difference did not reach statistical significance.
Our results suggest that there is a significant ceiling
effect of the DASH questionnaire in this cohort of athletes.
A ceiling effect is usually considered to be present if
the best possible score is achieved by 15% to 20% of
patients,4,28 and almost two-thirds of the athletes in our
cohort achieved a score of 0. The baseline function in the
athletic population is higher than the general population,
and the DASH outcome measure may be considered too
easy for this group. Previous studies have suggested that
ceiling effects may be a common limitation among current
outcome measures administered to athletes, because these
questionnaires were not designed to discriminate between
higher functioning individuals.2,8 Clarke et al7 reported
normative scores in various shoulder outcome measures,
including the ASES, SST, Single Assessment Numeric
Evaluation, Western Ontario Shoulder Instability Index,
and DASH in young active adults.7 In that study, the
median score for 4 of these outcome measures was the
highest attainable score, suggesting that a significant
ceiling effect is also present in those outcome measures in
young adults.
One of the goals of establishing normative data for
various populations is to define a benchmark for measuring
return of baseline upper extremity function after injury or
surgical intervention. However, the substantial ceiling
effect shown in our study and in the Clarke et al7 study
would limit the use of the established normative data. Our
study results suggest that the DASH questionnaire is not
sensitive to or capable of measuring the high physical
function of athletic individuals, and data from previous
studies on upper extremity specific outcome measures
stress the importance of examining the appropriateness of
these measures before use in highly active individuals.
Within our population of athletes, multiple statistically
significant differences existed between age, gender, and
sports subgroups. Our study confirmed the results of
previous studies of general health outcome measures and
other upper extremity outcome measures suggesting that
female gender and older age are associated with an
increased rate of musculoskeletal complaints and disorders.6,22 Brinker et al6 studied instrument bias in various
upper extremity outcome measures with regard to gender
and age and found that the Constant-Murley score showed
gender and age bias, but other scoring systems such as the
ASES had negligible bias.6 Although normative DASH
scores in the general population described by Hunsaker et
al18 were not stratified by age or gender, Jester et al20
demonstrated in their study of 716 adults that women had
significantly more upper extremity disability than men on
total DASH scores. Also when individuals were stratified
by age, they found that significantly increased functional
limitations accompanied increasing age.
In addition to differences between age and gender
subgroups, overhead athletes scored significantly worse on
both the total DASH score and the sports module score.
This is likely because athletes participating in overhead
The DASH questionnaire in intercollegiate athletes
sports are more prone to chronic shoulder pain and
dysfunction due to the large amount of stress placed on the
shoulder during the overhead throwing motion.23,25 Soldatis
et al,25 in a group of 190 healthy collegiate athletes
participating in overhead sports, previously determined that
significant shoulder symptoms exist in all athletes during
full participation in their respective sports. Those athletes
with a history of shoulder injury had increased frequency
and degree of symptoms. The results of our study correlate
well with these previous studies showing differences in
baseline DASH scores are dependent on gender and age
group, as well as participation in overhead sports.
The method of data collection in this study has its
limitations, and the interpretation of results must be viewed
in the correct clinical context. Although this study showed
statistically significant differences between athletes in our
group and differences between our group and other study
populations, the applicability of these differences may not
be of practical or of clinical significance. The minimal
detectable change and the minimal clinically important
difference for the DASH questionnaire has been reported to
be approximately 10.24 Score differences of 1 or 2 between
groups of patients in our study may not have clinical
relevance, although a difference of several points at baseline may be important when determining the effect size of
an intervention for this population of athletes. In addition,
the significant ceiling effect seen in this study minimized
the true differences seen between groups.
Other limitations of this study included possible nonresponse and response biases that may have affected our
results. Because these DASH questionnaires were being
administered to athletes undergoing clearance for participation in their respective sports, the overall DASH scores in
these athletes might have been artificially low due to
response bias in individuals wishing to appear as healthy as
possible.
Conclusion
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. A significant ceiling effect is present when the
DASH questionnaire is administered to these athletes
and limits the utility of using normative data in the
athletic population. Differences within our cohort and
differences between our cohort and other populations are
minimized by this ceiling effect. Other upper extremity
outcome measures may also be similarly limited by
a ceiling effect and should be examined for appropriateness in varying populations before use.
353
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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