J Orthop Sci (2006) 11:248–253
DOI 10.1007/s00776-006-1013-1

Original article
Validation of the Japanese Society for Surgery of the Hand
Version of the Quick Disability of the Arm, Shoulder,and Hand (QuickDASH-JSSH) questionnaire
Toshihiko Imaeda1, Satoshi Toh2, Takuro Wada3, Shigeharu Uchiyama4, Shuji Okinaga5, Koichi Kusunose6,
Takuya Sawaizumi7 for the Impairment Evaluation Committee, Japanese Society for Surgery of the Hand
1

Department of Public Health, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukakecho, Toyoake, Aichi 470-1192,
Japan
2
Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Hirosaki, Japan3
Department of Orthopaedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
4
Department of Orthopaedic Surgery, Suwa Red Cross Hospital, Suwa, Japan
5
Department of Orthopaedic Surgery, Tokyo Teishin Hospital, Tokyo, Japan
6
Department of Orthopaedic Surgery, Tokyo Rosai Hospital, Tokyo, Japan
7
Department of Orthopaedic Surgery, Nippon Medical School, Tokyo, Japan

Abstract
Background. The Quick Disability of the Arm, Shoulder, andHand (QuickDASH) questionnaire is a region-specific, selfadministered questionnaire, which consists of a disability/
symptom (QuickDASH-DS) scale, and the same two optional
modules, the work (DASH-W) and the sport/music (DASHSM) modules, as the DASH. After the Japanese version of
DASH (DASH-JSSH) was cross-culturally adapted and developed, we made the Japanese version of QuickDASH(QuickDASH-JSSH) by extracting 11 out of 30 items of the
DASH-JSSH regarding disability/symptoms. The purpose ofthis study was to test the reliability, validity, and responsiveness of QuickDASH-JSSH.
Methods. A series of 72 patients with upper extremity disorders completed the QuickDASH-JSSH, the 36-Item ShortForm Health Survey (SF-36), and the Visual Analog Scale(VAS) for pain. Thirty-eight of the patients were reassessed
for test–retest reliability 1 or 2 weeks later. Reliability wasinvestigated by the reproducibility and internal consistency.
To analyze the validity, a principal component analysis andthe correlation coefficients between the QuickDASH-JSSH
and the SF-36 were obtained. The responsiveness was examined by calculating the standardized response mean (SRM;
mean change/SD) and effect size (mean change/SD of baseline value) after carpal tunnel release of the 17 patients withcarpal tunnel syndrome.
Results. Cronbach’s alpha coefficient in the QuickDASH-DS
was 0.88. The intraclass correlation coefficient (ICC) for thesame was 0.82. The unidimensionality of the QuickDASH-DS
was confirmed. The correlation coefficients between the
QuickDASH-DS and the DASH-DS, DASH-W, or the
DASH-SM were 0.92, 0.81, or 0.76, respectively. The correlation coefficients between the QuickDASH-DS score and thesubscales of the SF-36 ranged from −0.29 to −0.73. The correOffprint requests to: T. Imaeda
Received: December 14, 2005 / Accepted: February 16, 2006

lation coefficient between the QuickDASH-DS score and the
VAS for pain was 0.52. The SRM/effect size of QuickDASHDS was −0.54/−0.37, which indicated moderate sensitivity.
Conclusion. The Japanese version of QuickDASH hasequivalent evaluation capacities to the original QuickDASH.

Introduction
Health measurement scales are important patient outcome tools to measure health status and evaluate medical intervention.1 Recently several measures for theevaluation of upper extremity function have been developed.2–7 Most of them are joint-specific2,3 or diseasespecific.4,5 Others are intended to evaluate the functionof the entire upper extremity using a region-specificmeasure.6,7 The Disability of the Arm, Shoulder, andHand (DASH) questionnaire was devised as a regionspecific measure by the American Academy of
Orthopaedic Surgeons (AAOS) in collaboration with anumber of other organizations.7 The rationale for use ofthis measure is that the upper extremity is a functional
unit or kinetic chain.8 Therefore, the DASH is suitable
for measuring health status outcome because it ismainly a measure of disability. The DASH is now available in several languages and in use in several countries.9–16 Studies of reliability and validity have been
published for not only the original version,17 but also for
the Japanese9 and other language versions.10–16
The QuickDASH was developed as a shortened
version of the DASH Outcome Measure.18 Instead of
the 30 items of the DASH Outcome Measure, theQuickDASH uses 11 items to measure physical function

T. Imaeda et al.: Validation of the JSSH version of the QuickDASH

and symptoms in people with any or multiple musculoskeletal disorders of the upper limb. Like the DASH
Outcome Measure, the QuickDASH also has two optional modules intended to measure symptoms andfunction in athletes, performing artists, and other workers whose jobs require a high degree of physicalperformance.
We, the Impairment Evaluation Committee (Japanese Society for Surgery of the Hand), have completed
cross-cultural adaptation and development of the
DASH Japanese version (DASH-JSSH) and reported
its reliability, validity, and responsiveness.9 After the
QuickDASH was released, we also developed the
QuickDASH Japanese version (QuickDASH-JSSH).
The purpose of this study was to test the reliability,
validity, and responsiveness of the QuickDASH-JSSH,
to compare them with those of the full DASH-JSSH,
and to make the QuickDASH-JSSH available for use inJapan.

Materials and methods
In accordance with published guidelines,19,20 we organized the DASH-JSSH committee consisting of translators, researchers, a methodologist, and a Japanese
language expert, and culturally adapted the full DASH
(version 2.0) into Japanese.9
After the QuickDASH was released by the AAOS,
we, the Impairment Evaluation Committee (JapaneseSociety for Surgery of the Hand), extracted 11 items
from the 30 items of the full DASH and adopted two
optional modules of the full DASH to develop the
QuickDASH Japanese version (QuickDASH-JSSH).
The QuickDASH-JSSH version was then evaluatedwith regard to reliability, validity, and responsiveness.
The QuickDASH questionnaire
The main part of the QuickDASH is an 11-item disability/symptom (QuickDASH-DS) scale concerning thepatient’s upper extremity.18 Each item has five response
choices, ranging from “no difficulty or no symptom” to“unable to perform activity or very severe symptom,”and is scored on a one-to-five scale. The items ask about
the severity of each of the symptoms of pain, activityrelated pain, tingling, weakness, and stiffness (twoitems: numbers 9,10), the degree of difficulty in performing various physical activities because of an arm,shoulder, or hand problem (6 items: numbers 1–6), theeffect of the upper extremity problem on social activities, work, and sleep (three items: numbers 7, 8, 11). The
psychological effect on self-image (one item: number30) in the full DASH was excluded in this QuickDASH.
These 11 items provide the DASH disability/symptom

249(DASH-DS) score ranging from zero (no disability) to100 (the severest disability), after summation of thescores from all items and transformation.
The QuickDASH, as does the full DASH, contains
two optional modules concerning the ability to work,and the ability to perform sports and/or to play musicalinstruments. These two optional modules each consistof four items, each of which has a one-to-five scale.
These provide the DASH work (DASH-W) score andthe DASH sport/music (DASH-SM) score ranging
from zero (no disability) to 100 (the severest disability),
after summation of the scores from all items andtransformation.
Patients and setting
A series of 73 patients with upper extremity disorders
was seen on an outpatient basis in five orthopedic surgery departments in Japan.9 Exclusion criteria were age
below 18 years, and relevant comorbidity (e.g., connective tissue disease). One patient with comorbidity ofsystemic lupus erythematosus (SLE) was excluded. The
study was conducted on a total of 72 patients (17 men,
55 women) with carpal tunnel syndrome (38 patients),
rotator cuff disease (10 patients), cubital tunnel syndrome (7 patients), thoracic outlet syndrome (4 patients), or others (13 patients). The mean age was 54.1
years (SD 14.9 years, range 20–81 years). After informed consent was obtained from the patients to participate in this study, they answered the DASH-JSSH
questionnaire, the official Japanese version of the 36Item Short-Form Health Survey (SF-36; version 1.2),21,22
and the Visual Analog Scale (VAS) [0–10 scale] forpain. The data collected from the 72 patients were used
as a baseline value. Among the 72 patients, the 38 who
had no treatment such as medication and rehabilitation
during the consecutive visits were readministered the
DASH-JSSH questionnaire and VAS for pain 1 or 2
weeks later. The 17 patients with carpal tunnel syndrome who received carpal tunnel release by three handsurgeons answered the DASH-JSSH questionnaire and
VAS for pain twice preoperatively and postoperatively(3 months after surgery). The protocol of this study wasreviewed and approved by the institutional review
board prior to implementation.
Assessment of reliability, validity, and responsiveness
Reliability was investigated by looking at the reproducibility and internal consistency based on the test–retest
method. The following analyses were conducted to examine the validity. A principal component analysis was
conducted to examine the construct validity and theunidimensionality of the QuickDASH-JSSH disability/
symptom (QuickDASH-JSSH-DS). Completeness of250

T. Imaeda et al.: Validation of the JSSH version of the QuickDASH

item responses of the QuickDASH-JSSH and VAS for
pain was examined. Correlation coefficients between
the QuickDASH-JSSH and the SF-36 were obtained,
and the following hypotheses were examined to investigate concurrent validity: (1) “physical functioning” (SF36-PF) or “role-physical” (SF-36-RP) would exhibit thestrongest association; (2) “bodily pain” (SF-36-BP)
would exhibit the next strongest association; and (3)“mental health” (SF-36-MH) and “vitality” (SF-36-VT)
would exhibit the weakest association. Correlation
coefficients between the QuickDASH-JSSH-DS andthe full DASH-JSSH-DS, the DASH-JSSH-W, or the
DASH-JSSH-SM scales were also obtained.
Correlation coefficients between the QuickDASHJSSH-DS and the SF-36 were obtained. Correlation coefficients between the QuickDASH-JSSH and VAS for
pain were obtained, and the criterion-based validity investigation looked at the following hypothesis: the correlation between the QuickDASH-JSSH and VAS for
pain would be high. The responsiveness was examinedby calculating the standardized response mean (SRM;
mean change/SD)23 and effect size (mean change/SD of
baseline value)24 after carpal tunnel release of the patients with carpal tunnel syndrome.
Statistical analysis
Kolmogorov–Smirnov and Lilliefors probability tests
were used to assess distribution of the QuickDASHJSSH and ages of the subjects. The interval measurement of QuickDASH-JSSH-DS was not normally distributed. Therefore, correlations between
QuickDASH-JSSH-DS and other instrument scales
were assessed using a nonparametric test (Spearman’s
correlation). Cronbach’s alpha was used to assess internal consistency. Instrument test–retest reliability wasassessed with the intraclass correlation coefficient(ICC).
All statistical analyses were conducted using the Statistical Package for Social Science (SPSS) version 12.0 J
software. The critical values for significance were set at
P < 0.05.

Results
Completeness of item responses
No patients had difficulty completing the DASH-JSSH
questionnaire.9 Most of the patients considered all theitems of the DASH-JSSH-DS section to be clear. Twoout of the 72 patients (nonrespondent group) did not
answer one item of the QuickDASH-JSSH-DS. One
patient did not respond to item 5. The other patient did
not respond to item 7. Fifty-five out of 72 (76%) pa-

tients answered the DASH-JSSH-W. However, only 15
out of 72 (21%) patients responded to the DASHJSSH-SM.9
The mean, median, and standard deviation of the
QuickDASH-JSSH scores were 28, 24, and 21, respectively. The numbers of ceiling and floor scoresof the QuickDASH-JSSH were identified. One patient
had a maximum disability score of 100 (floor) on
the QuickDASH-JSSH-DS. Three and four patients
had the minimum disability score of zero (ceiling)on the DASH-JSSH-W and the DASH-JSSH-SM,
respectively.9
Reliability
Internal consistency was assessed by use of Cronbach’s
alpha coefficient. The alpha coefficient for the 11 itemsin the QuickDASH-JSSH-DS was high (0.88). Whenthe alpha coefficient was calculated for each of the 11
items by eliminating each item, one by one, the range
was 0.87–0.88, and no items were found to change theinternal consistency substantially.
Instrument test–retest reliability was assessed with
the intraclass correlation coefficient (ICC). There were
38 patients for the test–retest reliability, and the period
between the first and second tests was a mean of 9.2
days (range 6–17 days). The ICC for the QuickDASHJSSH-DS was 0.82 (95% confidence interval: 0.69–0.90).
All ICCs for the QuickDASH-JSSH indicated sufficient
reproducibility.
Validity
A principal component analysis was conducted toconfirm the unidimensionality of the QuickDASHJSSH-DS. The first factor had an eigenvalue (amount ofvariation in the total sample accounted for by that factor)14 of 5.12, which explained the 47% total variance of
the QuickDASH-JSSH-DS scores of the patients(Fig. 1). The unidimensionality was found to be strong
as a result of a substantial difference between thefirst and the second factors (eigenvalue 1.74, Fig. 1).
When looking at the first factor loading for each item,
all items had loading (the correlation with the total
score) of 0.4 or higher (Table 1) and communalities ofmore than 0.4.
The
correlation
coefficients
betweenthe
QuickDASH-JSSH-DS and the DASH-JSSH-DS,
DASH-JSSH-W, or the DASH-JSSH-SM were 0.92,
0.81, and 0.76, respectively (Table 2, P < 0.01). These
results indicate strong correlations between the
QuickDASH-JSSH-DS and the DASH-JSSH-DS, between the QuickDASH-JSSH-DS and the DASHJSSH-W, and between the QuickDASH-JSSH-DS andthe DASH-JSSH-SM.

T. Imaeda et al.: Validation of the JSSH version of the QuickDASH

251

Table 1. Factor loading (unrotated) of principal components
Question no.

Item

LoadingqDASH-1
qDASH-2
qDASH-3
qDASH-4
qDASH-5qDASH-6
qDASH-7

Open a tight or new jar
Do heavy household chores (e.g., wash walls, wash floors)
Carry a shopping bag or briefcase
Wash your backUse a knife to cut foodRecreational activities which require little effort (e.g., card playing, knitting, etc.)
During the past week, to what extent has your arm, shoulder, or hand problem interfered withyour normal social activities with family, friends, neighbors, or groups?
During the past week, were you limited in your work or other daily activities as a result ofyour arm, shoulder, or hand problem?
Arm, shoulder, or hand pain
Tingling (pins and needles) in your arm, shoulder, or hand
During the past week, how much difficulty have you had sleeping because of the pain inyour arm, shoulder, or hand?

0.56
0.78
0.69
0.74
0.73
0.74
0.64

qDASH-8
qDASH-9qDASH-10
qDASH-11

0.81
0.44
0.69
0.60

Table 2. QuickDASH, DASH, SF-36, VAS, and theircorrelation
Instrument scale (N)DASH-DS (72)b
DASH-W (55)
DASH-SM (15)SF-36-PF (72)
SF-36-RP (72)
SF-36-BP (72)
SF-36-GH (72)
SF-36-VT (72)
SF-36-SF (72)
SF-36-RE (72)
SF-36-MH (72)
VAS (72)

Fig. 1. Scree plot of the principal components in disability/
symptom scale of QuickDASH-JSSH (QuickDASH-JSSHDS)

The correlations between the QuickDASH-JSSH-DS
score and the subscales of the SF-36 scale ranged from−0.29 to −0.73 (Table 2). The strongest correlation wasobserved in “role-physical,” followed by “physical functioning” and “bodily pain”. The correlation between
QuickDASH-JSSH-DS and “mental health” or “vitality” was somewhat weak. These results support the
hypothesis set down in advance, except the strongest
correlation (Table 2).
No statistical difference (P = 0.161) in age was foundbetween men (mean [SD], 50 [4.9] years old) andwomen (mean [SD], 55 [1.8] years old). The
QuickDASH-JSSH-DS scores between men (meanscore: 21.1) and women (mean score: 30.6) was compared by Mann–Whitney U-test. There was no statistical difference between them (P = 0.09). This result
supports our hypothesis. The correlation between the

Correlations
with QuickDASH-DSa
0.92**
0.81**
0.75**−0.69**−0.73**−0.63**−0.46**−0.35**−0.29**−0.54**−0.42**
0.52**

QuickDASH-DS, the Disability/Symptom scale of QuickDASHJSSH; DASH-DS, the Disability/Symptom scale of DASH-JSSH;
DASH-W, the work module of DASH-JSSH; DASH-SM, the sport/
music module of DASH-JSSH; SF-36-PF, Physical functioning
subscale of the 36-Item Short-Form Health Survey (SF-36); SF-36-RP,
Role-physical subscale of SF-36; SF-36-BP, Bodily pain subscale ofSF-36; SF-36-GH, General health subscale of SF-36; SF-36-VT, Vitality subscale of SF-36; SF-36-SF, Social functioning subscale of SF-36;
SF-36-RE, Role-emotional subscale of SF-36; SF-36-MH, Mental
health subscale of SF-36; VAS, Visual analog scale for pain (0–10
scale)aSpearman’s correlationb
Corrected for overlap** P < 0.01

QuickDASH-JSSH-DS score and age was weak (r =0.280, P < 0.05).
The correlation between the QuickDASH-JSSH-DS
score and the degree of pain was examined and observed as moderate for the SF-36 bodily pain score andthe VAS for pain (Table 2).
Responsiveness
Seventeen of 38 patients with carpal tunnel syndrome
received carpal tunnel release. They completed the252

T. Imaeda et al.: Validation of the JSSH version of the QuickDASH

QuickDASH-JSSH at 3 months after the surgery. The
mean subject age was 57 years (SD: 10 years, range:
48–78 years). There were 16 women and one man. The
differences between preoperative and postoperative
QuickDASH-JSSH-DS scores were not normally
distributed by Kolmogorov–Smirnov and Lilliefors
probability tests. Calculated SRM and effect size of
QuickDASH-JSSH-DS was −0.54/−0.37. The Wilcoxon
matched-pairs signed-ranks test was used to analyze
QuickDASH-JSSH-DS over time. There was a statistical difference between the median value of preoperative and postoperative QuickDASH-DS scores(P = 0.028, one-tailed).

Discussion
Japanese adaptation of the DASH questionnaire was
performed following a systematic standardized approach.19,20 The purpose of this study was to examine thepsychometric qualities of the QuickDASH-JSSH by assessing its psychometric standards in the area of thereliability, validity, and responsiveness.
The QuickDASH-JSSH consists of an 11-item scale
and two optional 4-item scale modules. It took patients asimilar amount of time to complete the full DASH-JSSH
compared with the time to complete the other language
versions.11 This may indicate that it will take them ashorter time to complete the QuickDASH questionnaire. In the full DASH, the elderly patients left no morethan three items unanswered, and those were thought topertain to specific activities, such as sexual activities andrecreational activities, that those individuals do not perform.9 In the QuickDASH such activities, especiallysexual activities from the full DASH, were eliminated.
That may explain why all patients except two completed
the QuickDASH. We can take advantage of the
QuickDASH instead of the full DASH especially in thecase of epidemiological studies in the workplace or whenmeasuring the health status of elderly people. The lack of
ceiling effects assure the authors of the validity of thisversion of the QuickDASH-JSSH-DS.
As for measurement precision, recommended reliability standards for individual-level applications range froma low of 0.90 to a high of 0.95, which is the desired
standard.25 Most general health status measures (e.g.,
SF-36, the Nottingham Health Profile [NHP], theFunctional status questionnaire [FSQ]),25 as well as
lesion- or joint-specific questionnaires (e.g., the Roland–
Morris Disability Questionnaire26 and Western Ontario
and McMaster Universities osteoarthritis index[WOMAC]27), cannot meet this standard, whether they
are designed for individual-patient applications orgroup-level applications. Most translated DASH versions10,12–15 as well as the original full DASH17 had inter-

nal consistency higher than 0.95. Beaton et al. reported
that the QuickDASH had internal consistency of 0.94 sothat QuickDASH has the potential to work well in themonitoring care of individual patients in clinical settings;18 but the QuickDASH-JSSH had internal consistency of 0.88. We may say that QuickDASH-JSSH could
be used with caution for daily assessment of individual
patient status. But as is stated in the DASH homepage(http://www.dash.iwh.on.ca/), because the full questionnaire provides greater precision, it may be the best
choice for clinicians who wish to monitor arm pain andfunction in individual patients. We would prefer that the
QuickDASH be used for groups of workers or patients.
The validation process of the QuickDASH-JSSH
questionnaire has shown that it has a similar validity tothe other language versions10,12–16 including the originalfull DASH.17 The strong correlations between the
QuickDASH-JSSH-DS and SF-36 subscales (role ofphysical health, physical functioning, and bodily pain)
support this validity and demonstrate similar results tothe validation papers for the other language versions
including the original full DASH. These results demonstrated that the QuickDASH-JSSH measures the important elements that make up health-related quality oflife (QOL).
The QuickDASH-JSSH-DS scale exhibited highunidimensionality and there was no low item–scale correlation. The communalities of this scale were very high.
These results show that the QuickDASH-JSSH-DS hasa high quality of validation.
Cohen’s rule-of -thumb for interpreting the “effectsize index,” i.e., a value of 0.2 is small, 0.5 is moderate,
and 0.8 or greater is large, can be applied to the SRM.23
The responsiveness of the QuickDASH-JSSH-DS for
patients with carpal tunnel syndrome was moderate 3months after carpal tunnel release operation, althoughother studies showed higher responsiveness of DASHDS than our results.28 There was a statistical difference
between the mean value of preoperative and postoperative QuickDASH-JSSH-DS scores.
We believe the strengths of this study are that the
QuickDASH-JSSH-DS scale demonstrated good reproducibility, consistency, and validity. Moreover, it had amoderate responsiveness.
A limitation of this study is that we cannot successfully
demonstrate the responsiveness of QuickDASH because
the sample size was relatively small and the patients’
response rate was low. Moreover, the samples of thisstudy are not representative of the general population.

Conclusions
We can conclude that the Japanese version of the
QuickDASH has equivalent evaluation capacities to the

T. Imaeda et al.: Validation of the JSSH version of the QuickDASH

original QuickDASH. We expect that the use of thisscale in Japan to assess treatment by the patients themselves will contribute to meaningful improvement ofoutcome for patients with upper extremity disorders.
Above all, the QuickDASH could be used for groups ofpatients.
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