A comparison of the Disabilities of the Arm, Shoulder, and Hand Outcome Measure and the
Michigan Hand Outcomes Questionnaire in external responsiveness over time
Rebecca Giallella, Jami McCall, Alayna Stitley, Katherine Warren,
Lynn Jaffe, ScD, OTR/L, FAOTA, Denise Allen, MHS, OT/L, CHT
Florida Gulf Coast University, Fort Myers, FL
PURPOSE
PROCEDURE
RESULTS
Clinicians need to select “best practice” outcome measures based on current
evidence of their success and use. Instruments should not only be selected for speed
and accuracy of patient progress, but also to accommodate for future insurance
changes and assurance of reimbursement.
The initial research packets were distributed to the participants by their occupational
therapists. These packets included a consent form, a patient information sheet, the
DASH, the MHQ, and the SF-12. They read and signed the consent form and filled
out the rest of the research packets at their convenience. The research packets were
returned via mail or directly to their occupational therapist.
• Significant positive correlation between the MHQ (R) initial score and the MHQ
(R) follow up score (p = .042, rs = .829)
• Significant correlation between the initial MHQ (L) score and the follow-up
MHQ (L) score (p = .019, rs = .886)
• Initial and follow-up scores for the DASH did not have significant correlation
(p = .468, rs = .371)
• SF-12 quality of life survey did not have significant correlation between initial
and follow-up scores
• MHQ (L) score showed significant correlation to the initial physical component
SF-12 score (p = .005, rs = .943)
• Neither MHQ (R) score nor DASH initial scores showed significant correlation
with either of the SF-12 quality of life scores.
Although the Disability of the Arm, Shoulder. And Hand Outcome Measure (DASH) is
the most commonly used Patient Report Outcome (PRO) measure, limited research
has been conducted to establish if this assessment is best at determining patient
outcome and disability. A 2015 study found that 49% of clients chose the Michigan
Hand Outcomes Questionnaire (MHQ), as the most accurate measurement of their
current hand function, while only 36% chose the DASH. No difference in
responsiveness between the DASH and MHQ was found, but participants selected the
MHQ as the best reflection of hand function (Weinstock-Zlotnick, Page, Ghomrawi, &
Wolff, 2015).
The researchers chose to analyze the MHQ assessment for this study based on its hand
specific qualities. This study sought to evaluate the external responsiveness of the
DASH compared to the MHQ as was previously conducted by Horng et al., 2010.
External responsiveness reflects the extent to which changes in a measure relates to
changes in other measures of health status (Roach, 2006).
The participants were then given follow-up packets two months after the initial
distribution, in order to evaluate change over time. The follow-up packets included
an instruction page, the DASH, MHQ, and the SF-12.
After gathering, scoring, and organizing the initial and follow-up data, the
researchers used a 2-tailed Spearman’s Rho (rs) to analyze statistical correlations,
and determine the external responsiveness of both the DASH and MHQ when
compared to the SF-12. Using raw data, the researchers were able to compute
output and assess correlations.
• The physical component
(PCS) and the mental
component (MCS) score did
not show correlation
between initial and followup score
• No correlation between
initial and follow-up scores
detected
• Significant correlation seen
between the DASH followup score and physical
component of SF-12 score
The current study replicated the Chinese investigation but substituted the Short Form
12 (SF-12) for the Chinese Health Questionnaire to yield relevant results in the United
States. External responsiveness was examined to determine changes in health status
over a two month period of time.
Disability of the
Arm, Shoulder and
Hand
(DASH)
Short Form 12
Quality of Life
Questionnaire
(SF-12)
Michigan Hand
Questionnaireleft hand
Michigan Hand
Questionnaire right hand
Participants in this study included individuals receiving treatment for hand and wrist
injuries at four Southwest Florida clinics. Six participants met inclusion criteria and
completed the study.
Disabilities of the Arm, Shoulder, and Hand (DASH): A PRO assessment used by
therapists, which is considered a valid, reliable self-report questionnaire that measures
perception of function in individuals with upper extremity conditions (Kennedy,
Beaton, Solway, McConnell, & Bombardier, 2011). Questions found on the DASH
pertain to functional tasks, pain, symptoms related to the injury, social implications,
and sleep in terms of being affected by the injured extremity.
Michigan Hand Questionnaire (MHQ): The MHQ is a PRO measure that assesses
overall hand function, activities of daily living, pain, work performance, aesthetics, and
overall patient satisfaction with current level of function (Ware, Kosinski, & Keller,
1996). It has been found to be valid, responsive, and moderately reliable (Chung &
Morris, 2014; Chung, Pillsbury, Walters, & Hayward, 1998). The domains are further
subdivided into right and left hand-specific questions with the exception of the work
performance domain.
Short-Form 12 (SF-12): A 12-question version of the SF-36, is a norm-referenced,
patient report quality of life survey. The decision to use the short version of the SF-36
was driven by a desire to reduce the length of the assessment and supported by
studies suggesting maintained integrity (Lam, Lam, Fong, & Huang, 2013). The SF-12
provides data regarding client’s perception of disability and their overall health and
well-being status.
• MHQ (L) initial score
correlated with the MHQ (L)
follow-up score
• MHQ (L) initial score
correlated significantly with
the physical component SF-12
initial score.
MHQ (L)
MHQ (R)
The MHQ in this study has been found to be more consistent and sensitive to
change over time. Both the right and left MHQ scores showed significant
correlation between the initial score and the two-month follow up score, as
opposed to the DASH, which demonstrated no correlation.
Research also indicated that the SF-12 did not show significant correlation to
change over time. In this study, the SF-12 did not seem to show significant
correlation with the DASH or MHQ. Even though physical function in clients
improved, based on DASH and MHQ scores, the physical component score (PCS)
derived from the SF-12 remained stagnant.
METHODS
The study was a quantitative, descriptive longitudinal design.
DISCUSSION
• MHQ (R) initial score
correlated significantly with
the DASH initial score
• MHQ (R) initial score
correlated with the MHQ (R)
follow-up score
REFERENCES
Chung, B. T. & Morris, S. F. (2014). Reliability and internal validity of the Michigan Hand Questionnaire. Annals of Plastic
Surgery, 73(4), 385-389. doi: 10.1097/SAP.0b013e31827fb3db
Chung, K. C., Pillsbury, M. S., Walters, M. R., & Hayward, R. A. (1998). Reliability and validity testing of the Michigan
Hand Outcomes Questionnaire. Journal of Hand Surgery, 23(4), 575-587.
Horng, Y., Lin, M., Feng, C., Haung, C., Wu, H., & Wang, J. (2010). Responsiveness of the Michigan Hand Outcomes
Questionnaire and the Disabilities of the Arm, Shoulder, and Hand Questionnaire in patients with hand injury.
Journal of Hand Surgery, 35(A), 430-436. doi: 10.10161/j.jhsa.2009.11.016.
Kennedy, C. A., Beaton, D. E., Solway, S., McConnell, S., & Bombardier, C. (2011). Disabilities of the Arm, Shoulder and
Hand (DASH). The DASH and QuickDASH Outcome Measure user’s manual, (3rd ed.). Toronto, Ontario: Institute
for Work & Health.
Lam, E. T. P., Lam, C. L. K., Fong, D. Y. T., & Huang, W. W. (2013). Is the SF-12 version 2 health survey a valid and
equivalent substitute for the SF-36 version 2 health survey for the Chinese? Journal of Evaluation in Clinical
Practice, 19(1), 200-208. doi:10.1111/j.13652753.2011.01800.x
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Weinstock-Zlotnick, G., Page, C., Ghomrawi, H. M. K., & Wolff, A. L. (2015). Responsiveness of three patient report
outcome (PRO) measures in patients with hand fractures: A preliminary cohort study. Journal of Hand Therapy ,
5(4), 1-8. doi:10.1016/j.jht.2015.05.004
By educating therapists in the clinical setting on the differences and benefits of
using different upper extremity assessment measures, it could change how therapy
is conducted, and can give therapists a better insight on their client’s abilities. This
can help therapists track progress, an important consideration with more strenuous
rules of billing taking effect. Being able to document progress using a reliable and
valid measure that is sensitive to change over time is crucial in order to receive
payment for services, and justify need for continued therapy.
RECOMMENDATIONS
1. In order to examine the DASH more effectively, it might be more appropriate to
use a one score format PRO as a comparison, instead of a two score PRO
measure, such as the MHQ.
2. Examining culture in relation to the DASH and MHQ would also be beneficial, to
see the effects of perception of function and quality of life. Cultural differences
may exist between populations, which could adjust perception and acceptance
of function.
3. Multiple research studies have validated the use of the MHQ, and have
described its ability to assess change over time more so than the DASH. Only
1% of therapists currently use the MHQ (Valdes et al., 2014), so additional
education may be required to help therapists realize benefits and ease of using
alternative assessments.
4. The profession may benefit from investing in more intensive research into
determining an outcome measure that has a higher degree of responsiveness
and therefore utility in assessment and reimbursement.