DISABILITY AND REHABILITATION,

2004;

VOL.

26,

NO.

14/15, 917923

A comparison of upper limb amputees and patients with upper limb injuries using the Disability of the Arm, Shoulder and Hand (DASH)
JUDITH DAVIDSON*
Occupational Therapist & Hand Therapist, Prince of Wales Hospital, Randwick, Australia
Abstract Purpose: To use the Disability of the Arm Shoulder and Hand (DASH) scale to measure the disability of patients with upper limb amputation(s) and to compare these to other upper limb injuries. Method: All 274 patients over the age of 18 years presenting to Prince Henry Hospital in Sydney over a 4-year time frame were given the DASH assessment tool and asked to complete it under supervision of the Occupational Therapist. Results: Patients with brachial plexus injuries, Complex Regional Pain Syndrome and bilateral upper limb amputations demonstrated signicantly higher levels of disability to patients with unilateral upper limb amputations. Partial hand amputees reported a higher level of disability than major unilateral upper limb amputees. For the 48 patients who completed pre- and post-treatment assessments, there was a signicant improvement in their health status. Conclusions: Further research is required to understand the factors that aect a patients perceptions of their disability. Perhaps the denitive nature of an amputation and the immediate involvement of highly skilled health professionals serve to assist patients to accept their injury and therefore minimizes the level of disability.

Introduction Amputation of a limb represents a catastrophe for the adult amputee and their family. However data regarding the prosthetic, functional and psychological outcomes achieved by these patients is limited. There is no well-recognized outcome measure for adults with an upper limb amputation used throughout Australia, UK or USA. The Hugh McMillan Centre, in Canada have published a Prosthetic Upper Extremity Function Index for use with children and their parents.1, 2 It is currently being used throughout several
* Author for correspondence; Prince of Wales Hospital, Barker Street, Randwick, NSW 2031, Australia. e-mail: judyd@accsoft.com.au

centres as a way of identifying the needs of children up to the age of 18 years. The Orebro Prosthetic Centre in Sweden is designing a new instrument to measure myoelectric prosthetic hand control in children but as yet it is not being widely used.3 Neither of these identies the psychological adjustment problems, which many of these amputees demonstrate. Donovan-Hall et al.4 have studied the psychological adjustment of 11 lower limb amputees awaiting the supply of a prosthesis with a silicone cosmetic cover. They report signicant behavioural limitations and discomfort, associated with low selfesteem, anxiety and depression when compared with an able-bodied control sample. Since lower limb amputees can wear trousers, shoes and socks to cover their prosthesis, the issue must be much greater for many upper limb amputees where the prosthesis cannot be covered in a socially acceptable fashion. Phantom limb phenomena are also a well-recognized problem for many upper limb amputees.5 Scales used to measure prosthetic use rarely investigate the impact pain has on the amputee and his or her well-being. The use of Quality of Life Scales could be used to measure the impact of psychological adjustment and pain, and the Nottingham Health Prole has been used with a variety of amputees in France.6 Although the report primarily assesses the reliability of the Nottingham Health Prole, it reports that mobility is the most impaired category for amputated subjects. Clearly this is not the case with upper limb amputees. Use of the SF36 would have the same problem in that the scale does not measure the impact of bilateral upper limb function. Heinemann et al.7 also report on an Orthotics and Prosthetics Users Survey as being a comprehensive set of clinical outcome instruments. The survey includes qual-

Disability and Rehabilitation ISSN 09638288 print/ISSN 14645165 online # 2004 Taylor & Francis Ltd http://www.tandf.co.uk/journals DOI: 10.1080/09638280410001708940

J. Davidson ity of life and clinic services but also includes a lower extremity functional status. The authors report that work is underway to evaluate a set of upper limb items. The Disability of the Arm Shoulder and Hand Scale (DASH) is an evaluative outcome measure for patients with upper extremity musculoskeletal conditions designed in the mid-1990s by the American Academy of Orthopaedic Surgeons and Toronto Institute for Work and Health.8 It is a region specic questionnaire as opposed to diagnosis specic questionnaire. It measures function and symptoms of musculo-skeletal disorders in upper limb. In the study by Hunsaker et al.9 it was used on a sample of normal subjects and was found to be a useful scale, which met assumptions for reliability and validity. Beaton et al.10 used the scale on 200 patients in Boston and Toronto with shoulder problems and wrist or hand problems. All subjects also completed the SF36. The DASH was able to demonstrate change in all situations in which change was presumed to have occurred. The DASH was found to have comparable responsiveness to the joint specic measures. It demonstrated suitable levels of sensitivity and specicity. Up until 1998, patients at Prince Henry Hospital in Sydney with injuries of their upper limb were not assessed using any formal questionnaires. All of the patients assessed were over 18 years as children are seen at a dierent hospital. There was an increasing need to formally measure outcomes and it was decided that the DASH being a region specic questionnaire was the most appropriate for a wide variety of diagnoses. The aim of this study was to use the DASH scale to measure the disability of people with upper limb amputation(s) and to compare this to the disability of people with other upper limb injuries.

Method
INSTRUMENT

The DASH asks about the patients ability to perform 21 physical activities on a 5-point Likert scale for degree of diculty or severity. Items include writing, food preparation, transportation, recreational needs, and changing a light bulb overhead. There are also three questions on psychosocial functioning and six on symptomatology. The totals of all 30 items are summed to produce a raw score. Thirty is deducted from the raw score and the total is then divided by 1.2 giving a total score out of 100. There are 2 optional sections about sport and work, which include four questions each. However these are calculated dierently. The four scores are summed and then four is subtracted from each score. The scores are then multiplied by 0.16 to give a total score out of 100. A higher score indicates a higher level of disability.
SAMPLE

Two hundred and seventy-four patients were given the DASH on initial assessment. There were 75 upper limb amputees in the cohort and 26 of these had partial hand or digit amputations. The remaining 199 patients suered a variety of diagnoses including Complex Regional Pain Syndrome, Shoulder Capsulitis, Carpal Tunnel Syndrome, and Brachial Plexus injuries (see table 1). Forty-eight of the patients were reassessed

Table 1 Diagnosis

The characteristics and mean DASH scores by diagnosis No. patients 4 2 35 26 8 10 42 21 13 4 10 6 17 37 25 14 274 Mean age 33 42 42 38 35 33 38 41 56 43 47 44 40 46 42 40 41 Mean DASH score 67 68 39 49 37 65 68 50 40 30 37 53 58 51 51 49 51 Standard deviation 18 5 20 22 16 15 19 22 21 23 14 19 16 17 22 17 21 No. compensable 0 2 19 16 5 8 40 14 3 3 5 5 16 33 18 10 197 No. non-compensable 4 0 16 10 3 2 2 7 10 1 5 1 1 4 7 4 77

Quadruple amputations Bilateral upper limb amputations Major unilateral upper limb amputation Partial hand amputation Amputation following brachial plexus injury Brachial plexus Complex regional pain syndrome Arm pain Carpal tunnel Fracture Arthritis Hand injury Radiating from neck Shoulder Tendonitis Wrist Total

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Comparison of upper limb amputees and upper limb injuries using DASH following treatment and 14 of these patients were upper limb amputees.
PROCEDURE

Over 48 months, all patients presenting to the Prince Henry Hospital in Sydney were given the assessment tool on their initial assessment and asked to complete it independently. For those patients who attended for treatment a number of times, an opportunity was given to complete the DASH again post treatment.
DATA ANALYSIS

The data was analysed using SPSS to produce average scores and standard deviations for those scores on the basis of diagnosis and compensability. Compensability refers to those patients whose injuries are covered by workers compensation and motor vehicle accident legislation and therefore all of the costs of treatment and income during time o work is funded by the relevant insurance company. Most of the results for the independent samples were analysed using the One Way Anova. However, the comparison of pre and post treatment scores were compared using the t-test for paired samples. Results The diagnoses, number of respondents, average age and the compensability of the patients is recorded in table 1 along with the average DASH score. The average DASH score for the whole cohort was 51/100. The highest average DASH scores were for bilateral amputations (68/100) and quadruple amputations (67/100) and patients with Complex Regional Pain Syndrome (68/100). The lowest average score was 30/ 100 for fractures. These diagnostic dierences are significant (F = 4.809, p 5 0.0001). There are major dierences within the scores by both diagnosis and compensability. Of the total cohort, 75% of injuries were covered by workers compensation or motor vehicle accident insurance. Within the highest 50 scores 96% (47) of patients were compensable. However in the lowest 50 scores 56% of injuries were compensable. Even the diagnoses of the patients in the cohort do not appear to be evenly distributed between the top and lower end of the scale. In the highest 50 scores there are 19 patients with complex regional pain syndrome but only seven amputees (and four of these were partial hand amputees). Within the lowest 50 scores there are 22

unilateral major upper limb amputees and only two patients with complex regional pain syndrome. The mean DASH score for dierent groups of patients by their compensability is listed in table 2. When all the 274 patients are compared by whether or not the injury was compensable there are signicant dierences. The non compensable patients have an average DASH score 15 units lower (F = 29.15, p 5 0.0001). Non-compensable amputees have an average DASH score 12 units lower than compensable amputees (F = 5.612, p 5 0.02). Table 3 shows the mean DASH scores for amputees compared to non-amputees. There is a 9 unit dierence which is signicant (F = 10.18, p 5 0.002). Table 4 shows the mean DASH scores for amputees by level of amputation. The mean score for brachial plexus injuries not proceeding to amputation was 65 compared to 37 for those brachial plexus injuries who have proceeded to amputation. The mean score for major unilateral upper limb amputation was 39/100

Table 2 Comparison of DASH scores by compensability of the patients Compensability All compensable participants All non-compensable participants Compensable amputees Non compensable amputees No 197 77 42 33 Mean DASH score SD 56 41 50 38 21 18 23 19 F = 5.612 p 5 0.02 Anova F = 29.15 p 5 0.0001

Table 3 Comparison of DASH scores and their standard deviation between amputees and non-amputees Category Amputee Non amputee No. 75 199 Mean DASH score 45 54 SD 22 21 Anova F = 10.18 p 5 0.002

Table 4 Comparison of DASH score and their standard deviation by level of amputation Amputation level Bilateral and quadruple Brachial plexus proceeding to amputation Major upper limb amputation Partial hand No. Mean DASH score SD 6 8 35 26 67 37 39 49 Anova

14 F = 3.95 16 p 5 0.012 21 22

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J. Davidson compared to partial hand amputation which was 49/100. This dierence was signicant (F = 3.95, p 5 0.01). The DASH score includes components for symptomatology (pain) and psychosocial status (esteem). Table 5 shows the mean esteem and pain scores for amputees compared to non-amputees. There is no signicant dierence between the pain scores but there is a signicant dierence on self-esteem (F = 5.73, p 5 0.017). The symptomatology and psychosocial scores for dierent levels of amputation are listed in table 6. The psychosocial status between the groups of amputees was signicant (F = 4.46, p 5 0.002) whereas there was no signicant dierence in the pain scores. Table 7 indicates the mean DASH scores for the 48 patients recorded on assessment and after treatment. The numbers are small in each of the categories. However, all of the categories of patients except those with pain radiating from the neck showed an improved health status in their DASH scores. Using the paired samples t-test the result is signicant (t = 4.24 p 5 0.0001). Of the 14 amputees who were reassessed, seven (50%) showed improved health status, three (21%) were unchanged and four (29%) had a diminished health status. Of the remaining 34 patients 26 (78%) showed improved health status, four (11%) were unchanged and four (11%) showed a diminished health status. Table 8 lists the mean DASH scores by diagnosis of the patients who completed the Work and/or Leisure module. Patients with Complex Regional Pain Syndrome and Brachial Plexus injuries saw themselves as having a severe level of disability on the main DASH

Table 5 Category

Comparison of pain and self-esteem scores and their standard deviation between amputees and non-amputees No. 75 199 Mean pain score 19 20 F = 0.425 p = 0.515 Pain SD 16 5 Mean esteem score 10 12 F = 5.73 p = 0.017 Esteem SD 3 6

Amputee Non amputee Anova

Table 6

Mean pain and self esteem scores and their standard deviations by level of amputation No. 6 8 35 26 Mean pain score 16 20 19 19 F = 0.069 p = 0.96 Pain SD 6 8 23 16 Mean esteem score 13 9 9 11 F = 4.465 p 5 0.002 Esteem SD 1 3 3 2

Amputation Bilateral and quadruple Brachial plexus proceeding to amputation Major upper limb amputation Partial hand Anovasignicance between levels

Table 7 Diagnosis

Comparison of assessment and post treatment scores using the DASH No. patients 1 9 3 1 3 10 2 2 2 1 8 3 3 48 Mean total DASH score 82 60 60 37 72 72 69 51 65 61 61 63 55 64 Mean total DASH score post treatment 47 45 47 20 47 52 51 46 63 68 36 43 19 44 Change in scores Down 35 Down 15 Down 13 Down 17 Down 25 Down 20 Down 18 Down 5 Down 2 Up 7 Down 25 Down 20 Down 26 Down 20

Quadruple amputations Major upper limb amputation Partial hand amputation Brachial plexus proceeding to amputation Brachial plexus Complex regional pain syndrome Arm pain Arthritis Hand injury Radiating from neck Shoulder Tendonitis Wrist Total

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Comparison of upper limb amputees and upper limb injuries using DASH
Table 8 Mean scores for the work and leisure module by diagnosis Diagnosis Multiple upper limb amputations Major upper limb amputation Partial hand amputation Brachial plexus proceeding to amputation Brachial plexus Carpal tunnel Arthritis Hand injury Wrist Complex regional pain syndrome Arm pain Radiating from neck Fracture Shoulder Tendonitis Total Anova Mean DASH score 71 39 47 34 66 38 23 52 45 65 44 58 30 42 49 51 F = 4.809 p 5 0.0001 No. leisure module patients 4 19 17 6 5 3 Nil 2 7 20 7 8 2 12 5 118 Mean leisure score 83 63 74 81 87 33 NA 50 93 91 66 79 81 98 45 77 F = 2.753 p 5 0.001 No. work module patients 3 23 14 5 7 8 5 3 7 29 12 12 4 28 15 176 Mean work score 77 87 80 82 80 43 41 41 80 90 64 79 76 77 60 73 F = 2.990 p 5 0.0001

score and also on the work and leisure modules. However, unilateral major upper limb amputees, amputees from brachial plexus injuries and partial hand amputees saw themselves as having a greater disability aecting work tasks. Interestingly multiple limb amputees and patients with shoulder injuries and fractures saw themselves as being more aected in leisure tasks than work tasks. Conclusions Health professionals have widely recognized that the level of amputation has no relationship to the psychological eects of the injury. The results of using the DASH in this study support this view. Many health professionals in Australia also believe that patients with compensable injuries have a higher perceived level of disability than those with noncompensable injuries. This research also supports this belief. It may be that those with compensation develop more anger because they can blame another person or organization for the injury or that the nancial reward from litigation also encourages an increased perceived level of disability. The non-compensable patient cannot attribute blame to any one else and may therefore nd it easier to accept the injury and face the future positively. The social security system in Australia provides a relatively poor standard of living and it is therefore likely that patients with non-compensable injuries have a nancial need to improve their functional status and return to independence and productive employment. Recognition and acceptance

of these issues may assist health professionals in simply understanding that compensable patients do have a higher degree of perceived disability and to provide psychological services to assist them in adjusting to their disability and returning to functional independence. The marked dierence in level of disability between brachial plexus injuries, which proceed to amputation, and those, which do not proceed to amputation, was surprising. Perhaps it is those patients who accept the long-term dysfunction who accept amputation. Acceptance of the injury can aid in reducing the level of disability. It may be that those patients with the brachial plexus amputations are in a more acute phase of their disability whereas the patients who have proceeded to amputation would nearly always be at least 12 months post injury and maybe this time span and treatment during this period results in the diering level of disability. Although all of the brachial plexus injuries that proceeded to amputation were provided with the chance to use a body-powered prosthesis, most were not successful and most eventually rejected the prosthesis. Both groups of patients were primarily performing functional activities using only one hand without the advantage of a good functional prosthesis. The relatively low scores of patients with a major upper limb amputation are perhaps a reection that they are a group of patients who are immediately recognized in health care facilities as needing immediate medical and rehabilitation care. They are almost always oered high technology prosthetic equipment. Perhaps the denitive nature of the injury assists them to come to terms with the amputation. Certainly, when they are scoring
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J. Davidson their responses, they mark their functional status scores on their ability with their intact arm initially and then their prosthetic arm. However, it appears that the high technology equipment assists them to cope better with daily tasks than work tasks. Patients with Complex Regional Pain Syndrome rated the highest level of disability on assessment compared to most other groups. Many of these patients had presented to other health care providers with what is a relatively minor injury and the pain gradually increases along with various physical restrictions. By the time they presented for this assessment they were confused and angry about the misunderstandings with other health care providers and the absence of any alleviation with their symptoms. Many present as being angry that no one has been able to help them or inform them as to what the problem is. Forty-eight patients in 13 diagnostic groups completed the post-treatment DASH. Twelve diagnostic groups, showed a better health status after treatment. The only group that showed a reduced health status were those with pain radiating from the neck. The time between initial completion of the DASH and the post treatment completion varied enormously among the patients. In addition, the relatively low response level after treatment makes it dicult to draw good conclusions from those scores. It may be that those patients who are not responding to treatment ceased attending and did not complete the post-treatment DASH. Other patients lived too far away and were referred elsewhere for treatment. In general there was a relationship between the DASH score and the DASH work and leisure scores with those with the greatest level of perceived disability on the DASH score having the highest perceived level of disability on the work and leisure scores. The work scores are clearly aected by the type of work that the patient normally performs and those whose work involves a lot of manual handling may well perceive themselves as more disabled than those in clerical or professional roles. It may also be that high technology equipment provided to upper limb amputees assists them more in the performance of their daily tasks than in the performance of manual handling work tasks and leisure tasks. The compensation system in Australia includes a focus on encouraging employers to oer suitable duties and this may aect a patients ability to work. Further research is required to better understand the factors that aect a patients perception of their disability and assist them to adjust to that disability. The DASH is a useful scale for measuring the health status of a patient with upper limb dysfunction. It is
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purported to quantify disability (predominantly physical function) and is a subjective measure designed to measure the patients perception of their disease. The scale is easy, simple to administer and relevant to a patients needs. It appears to encompass all cultures and provides an excellent guide to O.T. treatment. It gives an indication of the needs that the patient sees that they have. We have found it useful for outpatients but for inpatients with a new injury they have not had the chance to attempt the vast majority of the activities and they nd it very dicult to complete. The work and leisure modules are phrased dierently to the bulk of the DASH items. The bulk of the items are phrased so that the patient rates their level of diculty in performing the task. However the work and leisure module items compare their diculty in performing the tasks in a their normal way. This dierent phraseology may account for some of the results seen in this research. The measure is very useful for guiding Occupational Therapy treatment and especially for focusing on the physical functioning since their injury. If a patient scores the maximum score on the three psychosocial items, it can be used as an indication to discuss referring them to a psychiatrist. Likewise, severe symptomatology might necessitate a referral to an appropriate pain medicine specialist. The reason for the dierences in the patients perceived level of disability needs more research especially since their perceived level of disability can have such a marked eect on their performance in tasks.

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Comparison of upper limb amputees and upper limb injuries using DASH
7 Heinemann AW, Bode RK, OReilly C. Development and measurement properties of the Orthotics and Prosthetics Users Survey (OPUS): A comprehensive set of clinical outcome instruments. Prosthetics and Orthotics International 2003; 27: 191 206. 8 Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: The DASH (Disabilities of the Arm, Shoulder and Hand). The Upper Extremity Collaborative Group (UECG). American Journal of Industrial Medicine 1996; 29: 602 608. 9 Hunsaker FG, Cio DA, Amadio PC, Wright JG, Caughlin B. The American academy of orthopaedic surgeons outcomes instruments: normative values from the general population. Journal of Bone and Joint Surgery 2002; 84A(2): 208 215. 10 Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C. Measuring the whole or the parts? Validity, reliability and responsiveness of the disabilities of the arm, shoulder and hand outcome measure in dierent regions of the upper extremity. Journal of Hand Therapy 2001; 2(14): 128 146.

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