Validity of the Disabilities of the Arm, Shoulder and Hand patient-reported outcome measure (DASH) and the Quickdash when used in Dupuytren's disease

The construct validity and internal consistency of QuickDASH in pediatric patients with upper extremity fractures

BACKGROUND AND PURPOSE

Investigation of treatment options in the pediatric population necessitates the use of valid patient-reported outcome measures (PROMs). We aimed to assess the construct validity and internal consistency of the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) in the pediatric population with upper extremity fractures treated both operatively and conservatively.

PATIENTS AND METHODS

QuickDASH, along with several reference PROMs and objective outcome measures, was obtained from 148 5- to 18-year-old patients with a humeral medial epicondyle fracture or a fracture of the distal forearm in a cross-sectional setting with a single follow-up visit. Spearman's rank correlation and linear regression models were used to assess convergent validity, exploratory factor analysis (EFA) to assess structural validity, and Cronbach's alpha to investigate internal consistency.

RESULTS

The direction and magnitude of correlation showed by QuickDASH with reference outcome measures was consistent and demonstrated good convergent validity. EFA indicated a 3-factor model with poor fit indices and structural validity remained questionable. Construct validity was considered acceptable overall. QuickDASH demonstrated good internal consistency with an acceptable Cronbach's alpha (α = 0.75).

CONCLUSION

QuickDASH demonstrated acceptable construct validity and good internal consistency and is thus a valid instrument, with some limitations, to assess disability and quality of life in pediatric patients with upper extremity fractures.

Modified Scoring of the QuickDASH Can Achieve Previously-unattained Interval-level Measurement in Dupuytren Disease and Carpal Tunnel Syndrome

Background

Rasch measurement theory can be used to identify scales within questionnaires and to map responses to more precise continuous scales. The aim of this article was to use RMT to refine the scoring of the QuickDASH in patients with Dupuytren disease and carpal tunnel syndrome (CTS).

Methods

Data were collected between 2013 and 2019 from a single center in the UK. Preoperative QuickDASH responses from patients diagnosed with Dupuytren disease and CTS were used. RMT was used to reduce the number of items in the QuickDASH and examine the reliability and validity of each subscale.

Results

The preoperative QuickDASH responses of 750 patients with Dupuytren disease and 1916 patients with CTS were used. The median age of participants was 61 years, and 46% were men. Exploratory factor analysis suggested two distinct subscales within the QuickDASH: task items 1-6 and symptom items 9-11. These items were fitted to the Rasch model, and disordered response thresholds were collapsed. In Dupuytren disease, the two worst responses or each item were disordered. After collapsing these options, good Rasch model fit was demonstrated. CTS responses fitted without modification. Item targeting was more appropriate for CTS than Dupuytren disease.

Conclusions

This study proposes a modification to the scoring system for the QuickDASH that provides high-quality, continuous, and condition-specific scales for the QuickDASH. The identification of distinct subscales within the QuickDASH can be used to identify distinct improvements in hand function and/or symptoms in previous, current, and future work.

Psychometric sensitivity analyses can identify bias related to measurement properties in trials that use patient-reported outcome measures: a secondary analysis of a clinical trial using the disabilities of the arm, shoulder, and hand questionnaire

OBJECTIVES

Demonstrate psychometric sensitivity analyses for testing the stability of study findings to assumptions made about patient-reported outcome measures.

STUDY DESIGN AND SETTING

We performed secondary analyses of Disability of Arm, Shoulder, and Hand (DASH) data collected within the Prevention of Shoulder Problems clinical trial, which compared upper limb function scores in women who had undergone breast cancer surgery, randomized to either an exercise program or usual care. We repeated the principal trial analyses after grouping DASH items into subscales suggested by factorial analyses in this dataset and applied item response theory to account for unequal item weighting. We checked for measurement invariance by participant age and response shift bias using established techniques.

RESULTS

Our analyses suggested that the DASH measured two constructs: motor function and sensory symptoms. The majority of the six-month difference in DASH score was driven by motor function. With item response theory scoring, we found differences in both constructs at 12 months (P = 0.019 and P = 0.007), but in neither construct at 6 months, contrary to the original trial results. We found no differential item function by age or between baseline and 12-month measurements.

CONCLUSIONS

Psychometric sensitivity analyses aid in the interpretation of the Prevention of Shoulder Problems trial's results.

Responsiveness of the Arabic Quick Disabilities of the Arm, Shoulder and Hand in Patients with Upper Extremity Musculoskeletal Disorders

This study aimed to examine the responsiveness of the Arabic Disabilities of the Arm, Shoulder and Hand short version (Quick-DASH) in patients with upper extremity musculoskeletal disorders. Participants with upper extremity musculoskeletal disorders (N = 88) under physical therapy care were assessed at initial visit and later at a follow-up visit, and they completed the Arabic Quick-DASH, DASH, Numeric Pain Rating Scale (NPRS), Global Assessment of Function (GAF), and the Global Rating of Change Scale (GRC). Responsiveness of the Arabic Quick-DASH was assessed by examining six pre-defined hypotheses. Consistent with the pre-defined hypotheses, the Arabic Quick-DASH changes scores exhibited significant positive correlation with the change in DASH (r = 0.98), GAF (r = 0.67), NPRS (r = 0.72), and the GRC (r = 0.78). As hypothesized, the Arabic Quick-DASH showed a large effect size above the pre-determined level (ES = 1.61, SRM = 1.49) in patients who reported improved upper extremity function. The Arabic Quick-DASH change score discriminated between patients who reported improvement versus no improvement in upper extremity function (area under the receiver operating characteristic curve = 0.90). The results supported 100% (six out of six) of the pre-defined hypotheses. The Arabic Quick-DASH demonstrated sufficient responsiveness where all the pre-defined hypotheses were supported, leading to the established validity of the Arabic Quick-DASH change score as a measure of change in upper extremity function and symptoms. The minimal importance change in the Arabic Quick-DASH needs to be determined in future studies.

Effect of Perioperative Corticosteroid Administration on Early Postoperative Range of Motion and Functional Outcomes Following Dupuytren's Fasciectomy

BACKGROUND

The purpose of the study was to evaluate whether perioperative corticosteroid (CS) administration improves early postoperative range of motion (ROM) and function in patients undergoing Dupuytren's fasciectomy.

METHODS

We retrospectively identified 58 patients who underwent Dupuytren's fasciectomy by a single fellowship-trained orthopedic hand surgeon from 2016 to 2020. During this time period, 51 digits in 34 patients received a single intraoperative dose of 10 mg of intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course (CS group), and 37 digits in 24 patients did not (control group). Postoperatively, all patients started hand therapy within 1 week of surgery. At 2 and 6 weeks, patients had ROM data and Disabilities of the Arm, Shoulder, and Hand (DASH) scores collected by a blinded hand therapist. Paired t tests were used to compare the change in ROM and DASH scores at weeks 2 and 6.

RESULTS

The 2 cohorts had similar preoperative ROM. At 2 weeks postoperatively, the CS group had greater metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) flexion. There was no difference in MP, PIP, or DIP extension. At 6 weeks postoperatively, the CS group had greater PIP flexion. There was no difference between the groups in MP extension, MP flexion, PIP extension, DIP extension, or DIP flexion. Mean DASH scores were significantly lower in the CS group at weeks 2 and 6. There were no postoperative deep infections or complications requiring surgery in either group.

CONCLUSION

Perioperative CS administration appears to be safe and to improve early ROM and DASH scores following Dupuytren's fasciectomy.

Improving the structural validity of the QuickDASH questionnaire: Exploratory factor analysis and structural equation modelling in 1798 patients with carpal tunnel syndrome

STUDY DESIGN

Retrospective cohort.

BACKGROUND

The QuickDASH is a commonly used questionnaire for the assessment of carpal tunnel patients, although it is unclear whether the questionnaire has suitable structural validity PURPOSE: This study aimed to evaluate the structural validity of the QuickDASH patient-reported outcome measure (PROM), when used in CTS, through exploratory factor analysis (EFA) and structural equation modelling (SEM).

METHODS

Between 2013 and 2019, we recorded preoperative QuickDASH scores of 1916 patients undergoing carpal tunnel decompressions at a single unit. One hundred and eighteen patients with incomplete datasets were excluded leaving a final study group of 1798 patients with complete data. EFA was undertaken using the R statistical computing environment. We then conducted SEM in a random sample of 200 patients. Model fit was assessed using the chi-square (χ2) test, comparative fit index (CFI), Tucker-Lewis index (TLI), root mean square error of approximation (RMSEA) and standardized root mean square residuals (SRMR). A second "validation" SEM analysis was undertaken by repeating the analysis with a separate sample of 200 randomly-selected patients.

RESULTS

EFA revealed a 2-factor model: items 1-6 represented the first factor ("function") and items 9-11 measured a different factor ("symptoms"). SEM demonstrated excellent fit (χ2 p value 0.167, CFI 0.999, TLI 0.999, RMSEA 0.032, SRMR 0.046) and this was supported in our "validation" sample.

CONCLUSIONS

This study demonstrates that the QuickDASH PROM measures 2 distinct factors in CTS. This is comparable with the findings of a previous EFA that assessed the full-length Disabilities of the Arm, Shoulder and Hand PROM in patients with Dupuytren's disease.

A comparative analysis of multidimensional computerized adaptive testing for the DASH and QuickDASH scores in Dupuytren's disease

The QuickDASH is a short-form version of the DASH questionnaire, the most widely used patient-reported outcome measure in hand surgery. Multidimensional computerized adaptive testing (MCAT) can produce shorter and more precise testing than static short forms, like QuickDASH. We used DASH responses from 507 patients with Dupuytren's disease to develop a MCAT. The algorithm was evaluated in a Monte Carlo simulation, where the standard error of measurement (SEm) of scores obtained from the 11-item QuickDASH was compared with scores obtained from an MCAT that could administer up to 11 items from the full 30-item DASH. The MCAT asked a mean of 8.51 items (SD 2.93) and 265/1000 simulated respondents needed to complete ≤five items. Median SEms were better for DASH MCAT: 0.299 (hand function) and 0.256 (sensory symptoms) versus 0.320 and 0.290, respectively, for QuickDASH. Our study showed that the DASH MCAT can produce more precise DASH measurement than the QuickDASH, from fewer items.

Self-Reported Disability Following Surgery for Dupuytren Contracture in Diabetic and Non-Diabetic Patients

Background: The aims of this study were to investigate the impact of diabetes mellitus on patient-reported functional outcome measures (PROMs) and satisfaction following surgical treatment of Dupuytren contracture.

Methods: Preoperative and 1-year postoperative PROMs were collected prospectively over 6 years (2013–2019). Patients completed the QuickDASH score and were asked ‘how normal is your hand?’, recording responses on a 100-point visual analogue scale. Patient satisfaction was also self-reported.

Results: Paired responses were available for 520 hands (478 patients; 72% follow-up rate). There were 62 patients with diabetes (12%). Pre (12.5 vs. 9.1; p = 0.01) and postoperative (11.4 vs. 6.8; p = 0.02) QuickDASH scores were significantly, but not clinically, worse in diabetic patients. Patient satisfaction was high in both groups. A large and significant improvement in self-perceived hand normality was observed in both groups (p < 0.05). No significant differences were observed in preoperative or change in hand normality between the groups, but the postoperative normal hand score was significantly higher in non-diabetic patients (94 vs. 90; p = 0.02).

Conclusion: Our study has demonstrated statistically significantly worse disability in diabetic patients with Dupuytren contracture both pre- and postoperatively, though the observed differences were far below the minimum clinically important difference for the QuickDASH. Both groups reported a large and statistically significant improvement in self-perceived hand normality following surgery.

Level of Evidence: Level III (Therapeutic)

Nonresponder bias in hand surgery: analysis of 1945 cases lost to follow-up over a 6-year period

The primary aim of this study was to identify factors associated with nonresponse to routinely collected patient-reported outcome measures (PROMs) after hand surgery. The secondary aim was to investigate the impact of nonresponder bias on postoperative PROMs. We identified 4357 patient episodes for which the patients received pre- and 1-year postoperative questionnaires. The response rate was 55%. Univariate and regression analyses were undertaken to determine factors predicting nonresponse. We developed a predictive model for the postoperative Quick version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores for nonresponders using imputation. Younger age, increasing deprivation, higher comorbidity, worse preoperative QuickDASH scores and unemployment predicted nonresponse. No significant difference in mean postoperative QuickDASH score was observed between the responders, and the scores for the responders combined with the predicted scores for the nonresponders. Preoperative function was the primary predictor of postoperative outcome. These results challenge the dogma that 'loss to follow-up' automatically invalidates the results of a study.Level of evidence: III.

QuickDASH questionnaire items behave as 2 distinct subscales rather than one scale in Dupuytren's disease

STUDY DESIGN

Retrospective cohort BACKGROUND: Exploratory Factor Analysis (EFA) and structural equation modelling (SEM) assess relationships between questionnaire items and the constructs ("factors") measured by a questionnaire. The QuickDASH has not been subjected to these analyses in Dupuytren's disease.

PURPOSE

To undertake EFA and SEM to identify the factors measured by the QuickDASH in patients with Dupuytren's disease.

METHODS

We identified 750 cases of surgery for Dupuytren's disease at a single center with preoperative QuickDASH scores. We performed EFA on QuickDASH responses in R, using established methodology. Based on the EFA results, we conducted SEM in a training sample of 200 participants. A test SEM analysis was performed in a second, independent sample of 200 participants.

RESULTS

EFA suggested a 2-factor model. Items 1-6 measured one factor (we interpreted this as "hand function"), whereas items 9-11 measured a different factor ("hand symptoms"). Items 7 and 8 (social and work activities) did not reflect either of these factors well, and may be influenced by other variables. A structural equation model based on the EFA results, with 2 first-order factors, demonstrated excellent fit in our first SEM sample. This was confirmed with a second independent sample in a test analysis.

CONCLUSIONS

The QuickDASH PROM may measure 2 distinct factors in patients with Dupuytren's disease. This aligns with previous analyses of the full-length DASH PROM. Separation of the QuickDASH PROM into 2 sub-scales with distinct scores to measure "hand function" and "hand symptoms" may improve its structural validity in patients with Dupuytren's disease.

Psychometric evaluation of the disabilities of the arm, shoulder and hand (DASH) in patients with orthopedic shoulder impairments seeking outpatient rehabilitation

STUDY DESIGN

This is a cross-sectional, observational study.

INTRODUCTION

The disability of the arm, shoulder and hand (DASH) questionnaire is an upper-extremity specific outcome measure commonly used in routine clinical care and clinical trials.

PURPOSE OF THE STUDY

Our purposes were to: (1) examine the psychometric properties of the DASH questionnaire using factor analysis, one- and two-parameter item response theory models, and (2) develop a functional staging map illustrating the relationships between the item difficulty hierarchy of the DASH items and the patient's DASH total score.

METHODS

Data from 2724 patients with orthopedic shoulder impairments seeking outpatient physical therapy in 79 clinics in the US were analyzed.

RESULTS

Factor analysis supported a general factor, explaining 62.2% of the total variance. The coverage of DASH items was suitable for patients with shoulder impairments with no ceiling or floor effect. Endorsed items representing the most difficult items were related to feeling less capable, executing recreational activities with force or impact, and performing recreational activities in which you move your arm freely. Items with higher discriminating abilities were those related to do heavy household chores, garden/yard work, and change a light bulb overhead. With a separation index equaled to 4.94, the DASH can differentiate persons into at least 6 statistically distinct person strata. None of the DASH items exhibited differential item functioning by gender or symptom acuity, except two items by age group.

DISCUSSION

Besides a total (summed) final score obtained from a specific measure, the keyform and functional staging plots/maps can be used to assist clinicians in clinical interpretation of the scores.

CONCLUSIONS

Results supported the clinical usage of the DASH questionnaire in patients with orthopedic shoulder impairments seeking outpatient rehabilitation.

Factors Associated with the Development, Progression, and Outcome of Dupuytren Disease Treatment: A Systematic Review

BACKGROUND

The factors typically considered to be associated with Dupuytren disease have been described, such as those in the "Dupuytren diathesis." However, the quality of studies describing them has not been appraised. This systematic review aimed to analyze the evidence for all factors investigated for potential association with the development, progression, outcome of treatment, or recurrence of Dupuytren disease.

METHODS

A systematic review of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature databases was conducted using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant methodology up to September of 2019. Articles were screened in duplicate. Prognostic studies were quality assessed using the Quality in Prognosis Study tool.

RESULTS

This study identified 2301 records; 51 met full inclusion criteria reporting data related to 54,491 patients with Dupuytren disease. In total, 46 candidate factors associated with the development of Dupuytren disease were identified. There was inconsistent evidence between the association of Dupuytren disease and the presence of "classic" diathesis factors. The quality of included studies varied, and the generalizability of studies was low. There was little evidence describing the factors associated with functional outcome.

CONCLUSIONS

This systematic review challenges conventional notions of diathesis factors. Traditional diathesis factors are associated with disease development and recurrence, although they are not significantly associated with poor outcome following intervention based on the current evidence.

Hand function 5 years after treatment with collagenase Clostridium histolyticum injection for Dupuytren's disease

The aim of this study was to report hand function, disability and satisfaction and patients' perception of functionally troublesome contractures 5 years after injection with collagenase Clostridium histolyticum and hand therapy for Dupuytren's disease. Data from 79 patients were collected before and at 3, 12 and 60 months after treatment. Hand function was significantly improved, and 70% achieved a functional range of motion in the treated hand. QuickDASH scores and range of motion were best at 3 months follow-up. At 60 months, mean total extension deficit was 48°, which was 57% of the deficit before treatment. Thirty-seven patients (47%) had developed recurrent contractures in treated finger(s) meeting the criteria for new treatment. The threshold for functionally troublesome contractures was found to be 30°-60° in the finger joints. Treatment was experienced as painful, but few hand function problems occurred. Most patients would choose this treatment method again.Level of evidence: IV.

Validation of a Handprint for Clinical Evaluation of Dupuytren’s Contracture

Objective We have developed a handprint-based method for visualizing and quantifying the palmar contact of patients with Dupuytren’s contracture. The purpose of this study was to examine whether the generated handprint was useful for assessing the severity of flexion contracture of the fingers and for evaluating the therapeutic effects of collagenase clostridium histolyticum (CCH) injection for Dupuytren’s contracture.

Methods The handprint was created by applying medical-grade ethanol-containing hand sanitizer over the entire palmar surface of the affected hand and then pressing it on thermal paper for word processors. The reliability of the handprint was evaluated through test–retest of 10 healthy volunteers at an interval of 10 days, and the validity of the handprint was assessed using a flexion contracture model in which the little finger was fixed in an Alfence splint. In addition, we obtained handprints of the affected hand in 33 patients with unilateral Dupuytren’s contracture both before CCH injection and at the final observation after injection to investigate the contact area of the hand (CAH) and the length of the hand (LH). The relationships between CAH, LH, total extension deficit angle (TEDA), and patient-reported outcome measures (Japanese Society for Surgery of the Hand Version of the Quick Disability of Arm, Shoulder, and Hand Questionnaire [Quick DASH-JSSH] and Hand20) were examined.

Results The test–retest correlation coefficient was 0.9187 (p < 0.001) for CAH and 0.9052 (p < 0.001) for LH, indicating high reliability of the handprint. The ratios of CAH and LH decreased gradually as the contracture angle of the splinted finger increased. The handprint revealed a marked improvement of palmar contact after CCH injection for Dupuytren’s contracture. Furthermore, the ratios of CAH and LH were strongly correlated with TEDA, Quick DASH-JSSH, and Hand20 before treatment.

Conclusion Our handprint-based assessment method was extremely useful for clinical evaluation of CCH treatment for Dupuytren’s contracture.

Type of Study/Level of Evidence Therapeutic.

Self-Perceived Hand Normality Before and After Surgical Treatment of Dupuytren Contracture

PURPOSE

To describe patients' self-reported hand normality before and after surgery for Dupuytren contracture and to determine whether this metric could be used as an adjunct to determine the success of surgery.

METHODS

Preoperative and 1-year postoperative Quick-Disabilities of the Arm, Shoulder, and Hand and EuroQol 5-Dimensions 5-level scores were collected prospectively over 5 years. Patients were asked "How normal is your hand?" Scores were recorded on a 100-point visual analog scale. Outcomes were available for 296 patients (77%).

RESULTS

Median hand normality score improved significantly from 50 to 86 after surgery. Effect size of the change in normality was 1.2 SDs. The change in normality score correlated significantly with the Quick-Disabilities of the Arm, Shoulder, and Hand score. No significant floor or ceiling effects were observed.

CONCLUSIONS

This study introduced the concept of self-perceived hand normality in Dupuytren disease. Hand normality improved after surgery for Dupuytren disease, and this score performed favorably compared with preexisting outcome measures, which suggests it may be a useful adjunct to gauge the success of surgery.

CLINICAL RELEVANCE

This study introduces the concept of self-perceived hand normality in patients undergoing surgery for Dupuytren disease and quantifies improvement observed after surgery.

Measuring functional outcome in Dupuytren's disease: A systematic review of patient-reported outcome measures

BACKGROUND

Functional impairments related to Dupuytren's disease (DD) can be assessed using patient-reported outcome measures (PROMs). A systematic review was published in 2013 on outcome measures for assessing treatment in individuals with DD; however, several articles have since been published on this matter.

PURPOSE

To conduct a systematic review to analyze the quality and content of the evidence on the psychometric properties of PROMs used in individuals with DD.

STUDY DESIGN

Systematic review.

METHODS

CINAHL, EBM reviews, Embase, Medline, and Web of Science were searched to identify studies evaluating the psychometric properties of PROMs used with individuals with DD. All studies retained were appraised by two independent assessors using two validated critical appraisal tools.

RESULTS

Fifteen articles on the psychometric properties of 10 PROMs were included. Construct validity and responsiveness were the most studied. Eighty percent of the studies were of good to very good methodological quality according to MacDermid's Critical appraisal checklist for psychometric articles, whereas 67% of the studies comported risks of bias according to the COSMIN checklist. Of the 10 PROMs, three were specifically developed for DD but remain mostly under-studied for their psychometric properties (≤ 2 studies for the SDSS and DIF-CHUM). The QuickDASH, MHQ, BriefMHQ, and URAM present moderate to good convergent validity. Test-retest reliability was found to be good for the MHQ, briefMHQ, URAM, SDSS, SF-36, and the multi-attribute of the HUI-3. The MHQ and BriefMHQ are highly responsive.

CONCLUSION

There is a need for more psychometric studies on the PROMs used with individuals with DD. However, to date, the results included in this systematic review support that the MHQ and briefMHQ are the PROMs with the most acceptable psychometric properties.

Measurement properties of the Danish version of the Boston Carpal Tunnel Questionnaire

Background and Aims

Patient reported outcome measures are often used in medical research to evaluate symptoms and functional status in patients. The Boston Carpal Tunnel Questionnaire is specifically designed to evaluate functional status and symptom severity in patients with Carpal Tunnel Syndrome. The aim of this study was to validate and examine the measurement properties of the Functional Status Scale and Symptom Severity Scale from the Danish translated Boston Carpal Tunnel Questionnaire.

Material and Methods

We analyzed 88 prospectively enrolled patients in the validity and responsiveness group and 31 prospectively enrolled patients in the reliability group. Patients in the validity and responsiveness group answered the Quick Disabilities of the Arm, Shoulder and Hand Questionnaire and the Danish translated Boston Carpal Tunnel Questionnaire preoperatively and after surgery. Patients in the responsiveness group answered the same questionnaire two times prior to surgery.

Results

Responsiveness of the two subscales were high (Effect Size 0.99/1.76; Standardized Response Mean 0.86/1.50). Correlation to the Danish validated QuickDASH was high (rho 0.75/0.89). Test-retest reliability was high (ICC 0.94/0.90) and the internal consistency was high (Cronbach's alpha 0.93/0.92).

Conclusion

Our study shows satisfactory results of both subscales of the Danish translated Boston Carpal Tunnel Questionnaire. This makes it highly useful when conducting research on patients with Carpal Tunnel Syndrome.

Trial registration

The Danish Data Protection Agency: jr. nr. 2007-58-0010.

Development of a Patient-Based Goniometric System for the Assessment of Contracture Conditions in Dupuytren's Disease

BACKGROUND

Treatment outcomes of Dupuytren's disease depend largely on degree of contracture and biological severity. Longitudinal assessment of each is crucial for effective care and long-term outcome assessment. Ideally, each Dupuytren's patient should have ongoing interval evaluations. Because of the large number of Dupuytren's patients, it would be impractical and costly for health care professionals to examine every patient in person on a regular basis. Patient-based evaluations might provide a useful and cost-effective alternative to office-based examination.

METHODS

Finger goniometry is the standard metric for office-based evaluation of Dupuytren's disease. This study's goal was to develop a new patient-reported goniometric system. The authors developed a completely Web-based goniometric software for patients to use without supervision and without undue effort or cost. They then evaluated the validity and precision of the core measurement system and the reliability of its patient-based application.

RESULTS

With a correlation of 0.992 (p < 0.01), a mean deviation of -0.25 degree, and a standard deviation of 2.74 degrees in patient-based application, the authors found their goniometric software to be comparable to practitioner-based, conventional goniometry. The authors believe patient-based goniometry to be a sufficiently accurate, valid, and reliable approach for longitudinal clinical assessment of Dupuytren's disease.

CONCLUSIONS

Patient-based goniometric approaches have great potential for inexpensive, accurate, and accessible longitudinal assessment of the large population of Dupuytren's patients. Such approaches could help to substantially improve overall care of Dupuytren's disease through early diagnosis and timely treatment. In addition, being able to collect reliable patient data on a regular basis and on a larger scale could help improve understanding of the natural history of Dupuytren's disease.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, I.

The methodological requirements for clinical examination and patient-reported outcomes, and how to test them

This article presents the methodological requirements for clinical examination and patient-reported outcomes measurements. The assessment of any measurement for clinical research in hand surgery is difficult. A method of measuring a criterion could be 100% reliable but 100% invalid. Bias may be present in our assessment if we do not take into account the methodological requirements related to reliability, validity, and responsiveness of our measures. Reliability refers to intra-observer agreement, inter-observer agreement, or agreement between two methods of assessment, and, for patient-reported measures, internal consistency and test-retest reliability. Validity is the capability of a clinical method to measure what it proposes to measure. Assessing validity involves comparing a measure with one or more other measures, and, if possible, with a reference standard criterion. Responsiveness is the ability to detect important clinical change. The Consensus-based Standards for the Selection of Health Measurement Instruments provides the standards required for design and recommended statistical analyses of patient-reported outcome measures.

Which patient-reported outcomes shall we use in hand surgery?

Nowadays, the use of patient-reported outcome measures to monitor a treatment effect in daily practice or to quantify study outcomes is indispensable. In hand surgery, there is a wide variety available. This article provides an overview about the most common hand-specific, upper-extremity specific and general quality of life patient-reported outcome measurement instruments with adequate psychometric properties. A checklist and a decision tree are provided for choosing the appropriate instrument when evaluating patients with hand conditions.

Collagenase injections for Dupuytren disease: 3-year treatment outcomes and predictors of recurrence in 89 hands

Background and purpose - Few prospective studies have reported the long-term effect durability of collagenase injections for Dupuytren disease. We assessed the 3-year treatment outcome of collagenase injections and predictors of recurrence.Patients and methods - We conducted a single-center prospective cohort study. Indication for collagenase injection was palpable Dupuytren's cord and active extension deficit (AED) ≥ 20° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint. From November 2012 through June 2013, we treated 86 consecutive patients (92 hands, 126 fingers). A hand therapist measured joint contracture before, 5 weeks, and 3 years after injection. The patients rated their treatment satisfaction. Primary outcome was proportion of treated joints with ≥ 20° AED worsening between the 5-week and 3-year measurements. We analyzed predictors of recurrence.Results - 3-year outcomes were available for 83 of the 86 patients (89 hands, 120 treated fingers). Between the 5-week and 3-year measurements, AED worsened by ≥ 20° in 17 MCP (14%) and 28 PIP (23%) joints. At 3 years, complete correction (passive extension deficit 0-5°) was present in 73% of MCP and 35% of PIP joints. Treatment of small finger PIP joint contracture, greater pretreatment contracture severity, and previous fasciectomy on the treated finger were statistically significant predictors of recurrence. Treatment satisfaction was rated as very satisfied or satisfied in 59 of 87 hands. No long-term treatment-related adverse events were observed.Interpretation - 3 years after collagenase injections for Dupuytren disease, improvement was maintained and treatment satisfaction reported in two-thirds of the treated hands, with no adverse events. Complete contracture correction was achieved in 3 of 4 MCP joints, but in only a third of the PIP joints.

The Net Promoter Scores with Friends and Family Test after four hand surgery procedures

The Friends and Family Test, a variant of the Net Promoter Score, was adapted for the National Health Service to evaluate overall patient satisfaction and how likely patients are to recommend an intervention. It ranges from -100 to 100. Positive scores indicate good performance. This study quantifies the scores in 810 patients at a mean of 14 months following four common procedures. The score was 83 for trigger finger release ( n = 103), 68 for carpal tunnel decompression ( n = 467), 62 for surgery for Dupuytren's disease ( n = 224) and 44 for ganglia excision ( n = 16). Our study indicates that these procedures are highly valued and are recommended by patients according to the Friends and Family Test. The results of the Friends and Family Test correlated well with postoperative functional improvement and satisfaction. We conclude from this study that a compound score based on the Friends and Family Test is a useful addition to traditional measures of patient satisfaction. Level of evidence: II.

Surgical fasciectomy versus collagenase injection in treating recurrent Dupuytren disease: study protocol of a randomised controlled trial

INTRODUCTION

There is no definitive cure for Dupuytren disease (DD), and recurrence of finger contractures after treatment is common. Surgical fasciectomy is considered the standard treatment method for recurrence, although associated with a high incidence of complications. Collagenase injection, a non-surgical treatment option, has been shown to be a safe and effective method; however, most studies regarding collagenase have involved first-time treatment. Collagenase efficacy in patients with recurrent DD beyond the immediate effect has not yet been determined. The aim of our study is to compare surgical fasciectomy and collagenase injection in treating recurrent DD.

METHODS AND ANALYSIS

The study is a single-centre randomised controlled trial. Inclusion criteria are recurrence of DD in one or more fingers after previous treatment with fasciectomy or collagenase injection, a passive extension deficit ≥30° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint, and a palpable cord causing the recurrent contracture. A total of 56 patients will be randomised to either surgical fasciectomy or collagenase injection. A hand therapist blinded to patients' group allocation will measure range of motion at baseline, 3 months, 12 months, 24 months and 60 months. The primary outcomes are the total active extension deficit (MCP plus PIP) at 3 months and the proportion of patients with contracture worsening ≥20° in the treated finger joint at 2 years compared with 3 months. The secondary outcomes include changes in total active motion, active and passive extension deficit from baseline up to 5 years, scores on patient-reported outcome measures, adverse events and costs of treatment.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Regional Ethical Review Board, Lund University, Sweden(2017/623). The trial will be conducted according to the Helsinki Declaration of 1975, revised in 2000. The results of the trial will be disseminated as published articles in peer-reviewed journals.

TRIAL REGISTRATION

NCT03406338; Pre-results.

Revisiting the disabilities of the arm, shoulder and hand (DASH) and QuickDASH in rheumatoid arthritis

Background

Limitations in upper limb functioning are common in Musculoskeletal disorders and the Disabilities of the Arm, Shoulder and Hand scale (DASH) has gained widespread use in this context. However, various concerns have been raised about its construct validity and so this study seeks to examine this and other psychometric aspects of both the DASH and QuickDASH from a modern test theory perspective.

Methods

Participants in the study were eligible if they had a confirmed diagnosis of Rheumatoid Arthritis (RA). They were mailed a questionnaire booklet which included the DASH. Construct validity was examined by fit to the Rasch measurement model. The degree of precision of both the DASH and QuickDASH were considered through their Standard Error of Measurement (SEM).

Results

Three hundred and thirty-seven subjects with confirmed RA took part, with a mean age of 62.0 years (SD12.1); 73.6% (n = 252) were female. The median standardized score on the DASH was 33 (IQR 17.5–55.0). Significant misfit of the DASH and QuickDASH was observed but, after accommodating local dependency among items in a two-testlet solution, satisfactory fit was obtained, supporting the unidimensionality of the total sets and the sufficiency of the raw (ordinal or standardized) scores.

Conclusion

Having accommodated local response dependency in the DASH and QuickDASH item sets, their total scores are shown to be valid, given they satisfy the Rasch model assumptions. The Rasch transformation should be used whenever all items are used to calculate a change score, or to apply parametric statistics within an RA population.

Significance and innovations

Most previous modern psychometric analyses of both the DASH and QuickDASH have failed to fully address the effect of a breach of the local independence assumption upon construct validity.

Accommodating this problem by creating ‘super items’ or testlets, removes this effect and shows that both versions of the scale are valid and unidimensional, as applied with a bi-factor equivalent solution to an RA population.

The Standard Error of Measurement of a scale can be biased by failing to take into account the local dependency in the data which inflates reliability and thus making the SEM appear better (i.e. smaller) than the true value without bias.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2414-6) contains supplementary material, which is available to authorized users.

The Role of Hand Therapy in Dupuytren Disease

The role of hand therapy in the treatment of Dupuytren disease varies depending on the patient and the procedure. There is limited evidence for hand therapy as a preventive treatment of Dupuytren disease. Before corrective treatment, the hand therapist can contribute with assessments to promote evaluation of outcome. After corrective treatment, hand therapy is tailored to each patient's needs and consists of orthoses, exercise, edema control, and pain or scar management. Orthoses are usually part of the hand therapy protocol after corrective procedures despite lack of strong supporting evidence and should be provided based on individual patient needs.

The value of remembered pre-operative quick disabilities of the arm, shoulder and hand (QuickDASH) scores

It would be useful if it were possible for the patients to recreate their pre-operative QuickDASH scores in audits where this score had not been recorded before surgery. We assessed the accuracy of remembered pre-operative QuickDASH scores among 229 consecutive patients and the value of a previously developed algorithm for correcting these scores. Real pre-operative scores and remembered pre-operative scores were compared after a mean of 21 months. Furthermore, the scores of a subgroup of 79 patients with carpal tunnel syndrome, subacromial impingement, thumb basal joint arthrosis or Dupuytren's contracture were corrected using an algorithm. The mean difference between remembered and real pre-operative scores for all patients showed heteroscedacity in the Bland-Altman plot. The scores of the 79 sub-analysis patients were homoscedastic. The mean difference between remembered and real pre-operative scores was 9 (SD 16, SEM 1.85). Correcting the scores of the sub-group patients using our algorithm decreased the variation only moderately. The remembered pre-operative score is too inaccurate to be useful in individual patients, also when using our algorithm. However, subtracting nine from the mean remembered pre-operative score in a group of patients with any of the above diagnoses gives the real pre-operative score within the 95% confidence interval of four above and four below the real score.

Linguistic validation, validity and reliability of the British English versions of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and QuickDASH in people with rheumatoid arthritis

Background

Although the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is widely used in the UK, no British English version is available. The aim of this study was to linguistically validate the DASH into British English and then test the reliability and validity of the British English DASH, (including the Work and Sport/Music DASH) and QuickDASH, in people with rheumatoid arthritis (RA).

Methods

The DASH was forward translated, reviewed by an expert panel and cognitive debriefing interviews undertaken with 31 people with RA. Content validity was evaluated using the ICF Core Set for RA. Participants with RA (n = 340) then completed the DASH, Health Assessment Questionnaire (HAQ), Short Form Health Survey v2 (SF36v2) and Measure of Activity Performance of the Hand (MAPHAND). We examined internal consistency and concurrent validity for the DASH, Work and Sport/Music DASH modules and QuickDASH. Participants repeated the DASH to assess test-retest reliability.

Results

Minor wording changes were made as required. The DASH addresses a quarter of Body Function and half of Activities and Participation codes in the ICF RA Core Set. Internal consistency for DASH scales were consistent with individual use (Cronbach’s alpha = 0.94–0.98). Concurrent validity was strong with the HAQ (r_s = 0.69–0.91), SF36v2 Physical Function (r_s = − 0.71 - − 0.85), Bodily Pain (r_s = − 0.71 - − 0.74) scales and MAPHAND (r_s = 0.71–0.93). Test-retest reliability was good (r_s = 0.74–0.95).

Conclusions

British English versions of the DASH, QuickDASH and Work and Sport/Music modules are now available to evaluate upper limb disabilities in the UK. The DASH, QuickDASH, Work and Sport/Music modules are reliable and valid to use in clinical practice and research with British people with RA.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2032-8) contains supplementary material, which is available to authorized users.

Outcome measurement in plastic surgery

Outcome measurement in plastic surgery is often surgeon-centred, and clinician-derived. Greater emphasis is being placed on patient-reported outcomes (PROs), in which the patients' perspective is measured directly from them. Numerous patient-reported outcome measures (PROMs) have been developed in a range of fields, with a number of good quality PROMs in plastic surgery. They can be deployed to support diagnosis, disease severity determination, referral pathways, treatment decision-making, post-operative care and in determining cost-effectiveness. In order to understand the impact of disease and health interventions, appropriate PROMs are a logical choice in plastic surgery, where many conditions involve detriment of function or cosmesis. PROMS can be classified as disease-specific, domain-specific, dimension-specific, population-specific and generic. Choosing the correct outcome and measure can be nebulous. The two most important considerations are: is it suitable for the intended purpose? And how valid is it? Measurement that combines being patient-centred and aligning with clinicians' understanding is achievable, and can be studied scientifically. Rational design of new PROMs and considered choice of measures is critical in clinical practice and research. There are a number of tools that can be employed to assess the quality of PROMs that are outlined in this overview. Clinicians should consider the quality of measures both in their own practice and when critically appraising evidence. This overview of outcome measurement in plastic surgery provides a tool set enabling plastic surgeons to understand, implement and analyse outcome measures across clinical and academic practice.

Remembered preoperative Quick disabilities of the arm, shoulder and hand (QuickDASH) scores

The Quick disabilities of the arm, shoulder and hand (QuickDASH) patient-reported outcome measure is frequently used to assess disabilities and symptoms of the upper extremity. This study compares real preoperative QuickDASH scores and remembered preoperative QuickDASH scores. Remembered preoperative QuickDASH scores were obtained 45 months (39-67) after surgery. Patient material consisted of 160 patients operated for Dupuytren's contracture, carpal tunnel syndrome, thumb basal joint arthrosis, and shoulder pain. All patients had completed QuickDASH questionnaires before surgery. Paired T-tests, linear mixed models, and limits of agreement were used for analyses. There was a significant difference between remembered and real preoperative scores (mean 7.6, SD 15.6; SEM 1.2). Neither diagnosis, age, gender, nor time between surgery and review influenced the difference significantly. A linear mixed model was constructed to investigate the ability to retrospectively predict preoperative QuickDASH scores. Remembered preoperative QuickDASH cannot be used in individual patients because of the high inaccuracy.

LEVEL OF EVIDENCE

III.

Measurement Properties of the Brief Michigan Hand Outcomes Questionnaire in Patients With Dupuytren Contracture

PURPOSE

The brief Michigan Hand Outcomes Questionnaire (briefMHQ) was developed as a shorter version of the Michigan Hand Outcomes Questionnaire (MHQ), but its measurement properties have not been investigated in patients with Dupuytren contracture. The objective of the study was to investigate the reliability, validity, responsiveness, and interpretability of the briefMHQ.

METHODS

Fifty-seven patients diagnosed with Dupuytren contracture completed the briefMHQ as well as the full-length MHQ and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire at baseline. Two to 14 days after baseline and 1 year after collagenase injection or surgery, patients again filled out the briefMHQ. Reliability was determined using the intraclass correlation coefficient and by calculating internal consistency (Cronbach alpha). Validity was tested by quantifying correlations with the full-length MHQ and QuickDASH. Responsiveness, based on the standardized response mean and the minimally clinically important change, was also determined.

RESULTS

The briefMHQ had an intraclass correlation coefficient of 0.87, Cronbach alpha of 0.88, and correlations of r = 0.88 and -0.82 with the original MHQ and QuickDASH, respectively. The standardized response mean was 0.9 and the minimally clinically important change was 7 points.

CONCLUSIONS

Overall, the briefMHQ demonstrates excellent reliability, good validity, and high responsiveness in patients with Dupuytren contracture.

CLINICAL RELEVANCE

The briefMHQ is an accurate and time-saving tool to evaluate patients with Dupuytren contracture and the effect of a corresponding treatment.

Interpretation of the QuickDASH score after open carpal tunnel decompression: threshold values associated with patient satisfaction

We studied the correlation between change in the QuickDASH score and the absolute post-operative QuickDASH score with patient satisfaction after open carpal tunnel decompression. Threshold values in the QuickDASH score, the point at which the sensitivity and specificity are maximal in predicting patient satisfaction, were identified. During the study period, outcome data were compiled for 937 carpal tunnel decompressions, which included 219 (23%) male and 718 (77%) female patients with a mean age of 58 years (standard deviation (SD) 14). There was a significant improvement (mean difference 32, 95% confidence interval (CI) 30 to 34) in the QuickDASH from a mean of 54 (SD 20) to 22 (SD 23) at 1 year after surgery. There were 808 (86%) patients who defined their outcome as satisfactory at 1 year. The identified threshold values for the post-operative QuickDASH score (⩽34 points) and the change (⩾20 points) in the score were highly predictive of patient satisfaction. However, these threshold values varied significantly according to the baseline pre-operative score. The threshold values identified in the QuickDASH can be used to interpret the score. However, the influence of the pre-operative baseline score should be taken into account when comparing different cohorts of patients or using the values to power future studies.

LEVEL OF EVIDENCE IV

Prognosis, observational cohort study.