Translation into Brazilian Portuguese, cultural adaptation and reliability assessment of the Arm, Shoulder and Hand Disabilities Questionnaire (2023)

Braz J Med Biol Res, February 2005, Band 38(2) 293-302

Brazilian-Portuguese translation, cultural adaptation, and reliability assessment of the Arm, Shoulder, and Hand Disabilities Questionnaire

AG Orfale, P.M.P. Araújo, M. B. Ferraz and J. Natour

Fachgebiet Rheumatologie, Facultad Paulista de Medicina, Federal University of São Paulo, São Paulo, SP, Brasilien

patients and methods

references

correspondence and footnotes

The aim of this study was to translate, adapt and validate a Brazilian-Portuguese version of the Arm, Shoulder and Hand Disabilities (DASH) questionnaire. The study was conducted in two phases. The first was to translate DASH into Portuguese and make cultural adjustments, and the second was to determine the reliability and validity of DASH for the Brazilian population. 65 patients with rheumatoid arthritis, of either sex (according to the classification criteria of the American College of Rheumatology), between the ages of 18 and 60 years and without other diseases of the upper extremities were interviewed. Patients were selected sequentially in the UNIFESP Rheumatism Outpatient Clinic. The following results were obtained: In the first phase (translation and cultural adaptation), all patients answered the questions. In the second stage, Spearman's correlation coefficients for the interobserver analysis were between 0.762 and 0.995, values ​​that are considered very reliable. In addition, the intraclass correlation coefficients ranged from 0.97 to 0.99, which are also very reliable values. The Spearman correlation coefficients and the intraclass correlation coefficients obtained during the intra-observer evaluation ranged from 0.731 to 0.937 and from 0.90 to 0.96, respectively, which are very reliable values. The Ritchie Index showed a weak correlation with the Brazilian DASH scores, while the visual analogue pain scale showed a good correlation with the DASH score. We conclude that the Portuguese version of the DASH is a reliable tool.

Keywords:Disability of Arm, Shoulder and Hand (DASH), Brazilian Portuguese Translation, Disability, Questionnaire, Arthritis, Upper Limb, Validation, Arm

Several diseases affect the mobility of the joints of the upper limbs, including rheumatic, orthopedic and neurological diseases, amputations and other diseases. These diseases not only impair the proper function of the limb, but also cause pain, muscle weakness, instability, and compensation (1). Rheumatoid arthritis (RA) is a systemic disease that primarily affects articular, periarticular, and tendon structures due to inflammation of the synovial membrane. In this disease, involvement of the upper limbs can result in deformities that disable the joints (2,3).

The Disabilities Questionnaire of Arm, Shoulder and Hand (DASH) (4) was developed to measure physical disabilities and upper limb symptoms in a heterogeneous population, i. H. Men and women and people with mild, moderate or severe disabilities. and a variety of upper extremity disorders (5). The purpose of the DASH questionnaire is to describe differences between groups of subjects to compare the impact of upper extremity disorders and outcome measures. This instrument was developed to assess disability and symptoms associated with single or multiple upper extremity disorders (5).

The DASH questionnaire contains 30 questions measuring physical functioning and symptoms, including two questions about physical functioning, six questions about symptomology, and three questions assessing social functioning. In addition, there are two modules with four optional items: one for athletes/musicians and one for workers (5). The importance of the DASH is that it is the only questionnaire that assesses the upper limb as a whole. The quiz score is calculated using established formulas, one used to analyze the first 30 questions and the other used separately for optional modules.

The aim of this study was to translate the DASH into Brazilian Portuguese, apply a cultural fit, and assess its reliability for Brazilian patients.

patients and methods

The original English version of the DASH was translated and adapted according to the recommendations of Guillemin et al. (6,7) and Beaton et al. (8th).

Translation and back translation

Three English teachers (one of them a native English speaker) independently translated the original questionnaire and created three different versions of the questionnaire in Portuguese. The three translations were then compared and a consensus version (V1) of this translation was agreed.

The agreed version was then independently translated into English (back translation) by three other English teachers who were unaware of the original questionnaire. At the end of this phase, a new consensus version called V2 was created and compared to the original questionnaire to determine equivalence. This new English language version (V2) showed semantic and grammatical equivalence compared to the original version.

cultural equivalence

A meeting was then held with health professionals (rheumatologist, physiotherapist and occupational therapist) to evaluate the final version of the DASH. For questions 18 and 19, which relate to recreational activities that require strength or impact on the arms, shoulders or hands, or activities that involve free arm movement, the examples have been modified as the sports mentioned are unknown and therefore unsuitable are. for Brazilian patients. In question 18, golf or tennis was replaced with volleyball or hammering. In question 19, playing frisbee or "batting" (baseball) was replaced with playing cartwheels and fishing.

This Portuguese version of the DASH was applied by an interviewer to 25 consecutively selected RA patients at the Rheumatology Outpatient Clinic of the Federal University of São Paulo (UNIFESP). All patients met at least the four RA classification criteria (9,10). The mean age of this group (22 women and 3 men) was 48.25 years. All patients had upper extremity dysfunction.

All patients agreed to participate in the study. The main goal of this phase of the study was to determine understanding of the question. All questions were analyzed and those not understood were noted. If 20% or more of the patients did not understand an item, the question was modified and retested.

reliability and validity

After establishing cultural equivalence, the interviewers applied the questionnaire to a new group of 40 RA patients. DASH was applied three times, with the first two applications being performed on the same day by two investigators (appraiser 1 and investigator 2 – interobserver assessment) and the third assessment 5 to 8 days after the first application by investigator 1 (intra-observer) - observer evaluation). This new group of RA patients was selected by the same procedure as the first group and also had upper extremity dysfunction. The mean age of these patients (36 women and 4 men) was 50.70 years.

The validity of the DASH was tested by determining its relationship to other clinical parameters commonly used to assess patients with RA. Clinical outcome measures included a visual analog scale (VAS) for upper extremity pain and the Ritchie joint index (11), collected during questionnaire use.

Inter- and intra-observer reliabilities were determined using Spearman's correlation coefficient and the intraclass correlation coefficient (ICC).

Annex 1shows the original version of DASH in English andAttachment 2shows the final version of DASH in Portuguese.

Tabla 1lists the clinical and demographic characteristics of the 65 patients with RA included in the cultural adaptation phase of the Portuguese version of the DASH and in the validation phase of the questionnaire.

Spearman's correlation coefficient for the interobserver assessment was 0.937 for the DASH scores and 0.920 for the optional module, values ​​considered statistically significant (P<0.01) and therefore highly reliable. The ICC for inter-observer reliability was 0.99 for DASH scores and 0.97 for optional module correlations (P < 0.01).

In the intra-observer analysis, the Spearman correlation coefficient was 0.99 for the DASH scores and 0.95 for the optional module correlations, values ​​that were also statistically significant (p<0.01) and therefore reliable. The ICC for intraobserver reliability was also significant (P<0.01) and was 0.90 for DASH scores and 0.96 for optional module correlations.Table 2shows the mean (±SD) of the total score of DASH and optional modules and the coefficient of Spearman and the ICC.

Spearman's correlation coefficient between DASH and the optional DASH module was 0.797 (P<0.01). The correlation between DASH and VAS was 0.617 (P<0.01) and the correlation between DASH and Ritchie was 0.393 (P<0.05). All values ​​found were significant, but the correlation between DASH and EVA was stronger than the Ritchie index (P < 0.01) with values ​​of 0.468 and 0.495, respectively.

This is the first study to use DASH in patients with RA; All previous studies of this type have been conducted in other diseases. Navsarikar et al. (12) studied patients with psoriatic arthritis, Rosales et al. (13) patients with carpal tunnel syndrome and Offenbaecher et al. (14) studied patients with shoulder pain, which can be the result of non-specific rheumatic diseases. Dubert et al. (15) studied patients with traumatic diseases and disorders affecting the soft tissues of the upper extremity. The importance of the results obtained with the use of DASH in RA becomes clear when one considers the frequency of the disease and the involvement of the upper extremities, since RA is a systemic disease affecting all joints, but mainly those of the upper extremities, from the shoulder joints to the smaller joints of the hand. In addition, there is a lack of high quality tools to assess the upper extremities as a whole.

After translation, the DASH proved to be close to the Brazilian reality, as only the examples in two questions in the Portuguese version had to be modified to adapt the instrument to the Brazilian population. The first change related to the example in question 18, where tennis or golf was replaced by volleyball or hammering because few people can play tennis in Brazil and golf is not a popular sport. Similarly, in Question 19, playing Frisbee or "batting" (baseball) was replaced with fishing or badminton. In Brazil, baseball is a rare sport and frisbee is rarely practiced. It is important to note that these changes did not change the context of the question, which remained as "leisure activities that require exertion or impact on the arms, shoulders, or hands" and "leisure activities in which the arm moves freely," respectively . The study by Rosales et al. (13), in which the DASH was translated into Spanish, questions 18 and 19 were also amended. Question 18 retained the golf and tennis practice examples but added hammer shots and playing behind the wheel. However, for question 19 the example was swimming, bearing in mind that this question relates to free arm movement.

In the present study, the interviewers used the DASH questionnaire because in Brazil most patients are not used to it or do not have enough education to answer self-completed questionnaires. Therefore, the interviewers' use of the DASH aimed to increase the population to which the questionnaire could be applied and to avoid low educational attainment, as was the case with other questionnaires (16-19).

Navsarikar et al. (12), who studied patients with psoriatic arthritis, found a mean value of 27.5 (SD = 24.6). Jain et al. (20) in a study of patients with upper extremity deficiency reported DASH scores ranging from 21 to 99, with scores ranging from 21 to 40 in 4 participants, from 41 to 60 in 9, from 61 to 80 in 8, and from 81 to 99 in 22 subjects, the latter result being the highest compared to other studies. In contrast, Beaton et al. (21) in a study on diseases affecting the wrist, hands and shoulders observed similar DASH scores as in the above studies with a mean of 43.9. It is important to note that the higher the score, the worse the patient's condition.

In the present study, the mean disease duration was 13.63 years (range 1 to 31 years). Although Navsarikar et al. study another disease. (12) reported a similar duration (13.11 years) for patients with psoriatic arthritis.

When assessing intra- and inter-observer reliability, Spearman's correlation coefficient and the ICC showed highly satisfactory correlations for DASH scores and the optional DASH module. The analysis revealed a significant correlation between the DASH and the VAS of upper extremity pain. However, the Ritchie index correlation was significant but weak, probably because in these patients not only the joints of the upper but also the lower extremities were swollen, while the questionnaire only refers to the upper extremities. Likewise, Navsarikar et al. (12) also reported a high correlation between DASH and swollen joints of the upper extremities, while comparison with the total number of swollen joints showed no correlation.

The mean DASH scores obtained during the intraobserver assessment were 27.28 (SD = 19.11) and 26.49 (SD = 18.52) for the first and second assessments, respectively, with a Spearman coefficient of 0.937. Rosales et al. performed two evaluations. (13) obtained person correlation coefficients between 0.85 and 0.97. On the other hand, when assessing interobserver reliability, mean scores of 27.28 (SD = 19.11) and 27.67 (SD = 19.00) were obtained for the first and second ratings, respectively, with a coefficient of Spearman's mean of 0.995.

Rosales et al. (13) reported a high level of equivalence for the Spanish version of the DASH. Dubert et al. (15) stated that the DASH is an objective measure that provides specific scores that help compare different treatment specialties. Navsarikar et al. (12) concluded that DASH can be used in clinical trials as it reflects disease activity and joint weakness; however, it does not reflect deformities or disabilities that were adjusted during the disease process. We also found that DASH cannot detect deformities when the patient is already adjusted to their new condition. However, it is not important how the activity was performed, but rather how it was performed, as the DASH score indicates difficulty or inability to perform the task, according to other researchers. Probably because of this "defect", real rather than apparent difficulties are recognized. If the deformities do not interfere with performing activities, they do not affect the DASH score.

The DASH Sports/Music Exercise Module may be biased in that some patients do not experience difficulty playing a musical instrument but do experience difficulty in playing a sport, particularly when the sport requires exertion or stress. This module should be used in studies where the entire sample population performs the same job; otherwise it should be optional, ie the module should only apply to patients who practice the same sport or play the same instrument. However, more studies are needed on this module.

The Brazilian-Portuguese version of the DASH proved to be a reliable and valid tool for assessing the upper extremity in Brazilian patients, and its scores correlated strongly with the VAS for pain and weakly with the Ritchie index.

Delivery address:J. Natour, Discipline of Rheumatology, UNIFESP, Rua Botucatu, 740, 04023-900, São Paulo, SP, Brazil. Email:jnatour@reumato.epm.br

Release supported by FAPESP. Received: January 14, 2004. Accepted: August 12, 2004.

correspondence and footnotes