The cross-cultural adaptation of the disability of arm, shoulder and hand (DASH): a systematic review

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1 OCCUPATIONAL THERAPY INTERNATIONAL Published online 13 May 2008 in Wiley InterScience ( The cross-cultural adaptation of the disability of arm, shoulder and hand (DASH): a systematic review NASER M. ALOTAIBI, School of Occupational Therapy, Texas Woman s University, Houston, Texas, USA ABSTRACT: A systematic review of cross-cultural adaptations of the Disability of Arm, Shoulder and Hand into other languages was undertaken focusing on the translation and adaptation process, the problems during the translation process and proposed solutions. Nine articles were selected for analysis. All were written in English and addressed the qualitative issues of the cross-cultural adaptation process. The results demonstrated strong evidence that translation, adaptation and technical issues are most influential in the cross-cultural adaptation process. Awareness, understanding and incorporation of these issues will assist in future translations and adaptations of occupational therapy evaluation tools for use in other countries with different cultures. Implications for occupational therapy education, practice and research are discussed.. Key words: upper extremity assessment, translation, cross-cultural occupational therapy Introduction Because of the diversity of the world s cultures and increased globalization over the past two decades, the importance of using assessments across cultures has been recognized by educators, clinicians and researchers (International Test Commission, 2000; Van de Vijver, 2002). Also, because of the widespread development of psychometrically sound assessment tools in more advanced countries, the trend and the focus of international researchers is directed towards translation of these instruments into another language and/or culture (Geisinger, 1994). From an occupational therapy perspective, the availability of assessments adapted for use in a different culture promotes the clients capacity to engage in culturally meaningful occupations, a core belief in the occupational therapy profession (AOTA, 2002; Odawara, 2005; Clark et al., 1991). It is also consistent

2 Cross-cultural adaptation of the disability of arm, shoulder and hand 179 with the assertion that occupational therapists are increasingly concerned about the needs of people in countries seeking to improve health-related services (Bourke-Taylor and Hudson, 2005). Thus, a great number of assessment tools that have been developed initially in one language are then translated and validated into other languages (Gandek and Ware, 1998). The translation and validation processes, consequently, should adhere to the contextual and cultural needs of the population evaluated. This stage requires a fi rm basis for cross-cultural adaptation (Matias-Carrelo et al., 2003). Defi nition of cross-cultural adaptation Cross-cultural adaptation is defi ned as a process which looks at both language (translation) and cultural adaptation issues in the process of preparing a questionnaire for use in another setting (Beaton et al., 2000, p. 3186). Cross-cultural adaptation of questionnaires or outcome measures involves equivalency between the source and target versions based on four dimensions: (1) semantic equivalence; (2) idiomatic equivalence; (3) experiential equivalence; and (4) conceptual equivalence (Guillemin et al., 1993). Semantic equivalence determines whether the meaning of words is identical between the source and target languages. Second, idiomatic equivalence investigates how colloquialisms and idioms of the source language can be translated to the target language. Third, experiential equivalence addresses whether the activities of daily living in the source and target cultures are identical. And fourth, conceptual equivalence reflects whether similarity of concepts exists between the two cultures. DASH questionnaire The Disability of Arm, Shoulder and Hand (DASH) upper extremity outcome measure, which was developed by the American Academy of Orthopedic Surgeons and Institute for Work & Health (IWH), was designed to assess the symptoms and functional status of clients with upper limb conditions (Hudak et al., 1996). It contains 30 items, the majority of which describe the degree of difficulty the client faces while performing various physical activities due to arm, shoulder or hand problems (21 items). Also, it documents the severity of each of the symptoms of pain, activity-related pain, tingling, stiffness and weakness (five items). Moreover, the DASH describes problems that affect social activities, work, sleep and the psychological impact (four items) (Atroshi et al., 2000). In addition, the DASH contains two four-item optional modules that are scored separately from the 30-item DASH. These modules concern the client s ability to perform sports and/or to play a musical instrument (sport/music scale), or the ability to work (work scale). These optional modules are intended for athletes, performing artists or workers whose occupations require high levels of physical

3 180 Alotaibi performance. Such clients might have difficulties at these high performance levels that are beyond the scope of the 30-item DASH. Each item has five response choices that range from 1 without difficulty or no symptom to 5 unable to engage in activity or very severe symptom. At least 27 of the 30 items must be completed for a score to be calculated. The assigned values for all the completed responses are summed and averaged, producing a score of 5, and then this value is transformed to 100 by subtracting 1 and multiplying by 25, so it will be easier to compare to other measures that use 0 to 100 scales. The same procedure is used with the optional modules, provided that all the questions are answered (Atroshi et al., 2000). The DASH upper extremity questionnaire serves as an exemplary outcome measure that can be used in the clinical environment. It is standardized, easily administered, time efficient, applies to various conditions, involves the client in the evaluation process, addresses the functional status of clients and reports the client status at the time of assessment. It can be used to monitor client status over time and measure the therapeutic effectiveness of a particular program. Moreover, the DASH plays a key role in supporting evidence-based practice. Hence, it is a tool that tracks the client s outcomes across a continuum of care, provides evidence of the therapeutic outcome of services, supports the credibility of health professions and thus improves the quality of care (Johnson, 1998; Kielhofner and Forsyth, 2001). Due to its popularity, the DASH has been translated to many different languages (The DASH Outcome Measure, 2007). Rationale The rationale of this study was to conduct a systematic review of the issues related to the cross-cultural adaptation process of outcome measures. Hence, the goal is to discuss issues pertaining to the translation and adaptation of the DASH into other languages with a view to answering three questions: (1) How does the translation and adaptation process take place? (2) What are the known problems during the translation and adaptation process? (3) What are the suggested solutions to these problems? Method Systematic review process The current systematic review process used the guidelines described by Law and Philp (2002). The aim of the study was to understand the process of crosscultural adaptation of occupational therapy assessments and determine its implications to cross-cultural occupational therapy. To meet the review objectives, the process included seven sequential stages. Stage 1: The objectives of the

4 Cross-cultural adaptation of the disability of arm, shoulder and hand 181 review were clearly stated to guide setting of criteria. Stage 2: Inclusion criteria of relevant studies were described. Stage 3: Search strategies for identification of studies were developed. Stage 4: Published search results were screened. Stage 5: Relevant scientific studies that meet the inclusion criteria were identified and organized for analysis. Stage 6: The results of relevant studies were presented and analysed. Stage 7: Summary of the review was presented. Criteria for considering studies for this review The following inclusion criteria were developed, which were based on content: Studies of all the translated versions of the DASH outcome measure. Studies that were published in indexed or non-indexed journals (i.e., US and international journals). Studies that were written in English. Studies that discussed qualitative issues related to the DASH cross-cultural adaptation process. Search strategies for identifi cation of studies To identify relevant published studies, the investigator used the computerized databases of Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature (CINAHL); Educational Resources Information Center (ERIC), Health Source-Consumer Edition, Medline, and PsychINFO from 1994 to Other non-indexed international computerized databases were used. The DASH was developed in Hard Copy Search: The investigator reviewed bibliographies and databases on the cross-cultural adaptation of the DASH. Citation Review. Reference lists within the articles were examined for other related articles. Key Words Search: The search for articles on the cross-cultural adaptation of the DASH involved using single and combined key words. Key words included the following: Disability of Arm, Shoulder and Hand (DASH) Translation Cross-cultural adaptation Upper extremity disorders Upper extremity injury Results The search strategy resulted in 14 articles, nine of which met the stated inclusion criteria (Table 1). The remaining articles were excluded because they were

5 182 Alotaibi TABLE 1: Languages and publications of translated DASH questionnaires Language Language of publication (if published) Articles included in the review Armenian and Russian English Chinese (Hong Kong version) English Chinese (Taiwanese version) English French (Canadian version) English French (Parisian version) French German (version 1) English German (version 2) German Hebrew Japanese English Korean Norwegian Spanish English Spanish-Puerto Rico Swedish English Turkish Dutch English Italian English Portuguese (Brazilian version) English Greek English Lithuanian Hungarian written in languages other than English or they did not discuss the qualitative issues such as the problems encountered within the cross-cultural adaptation process and their resolution. Methodology used in the translation and adaptation process All of the studies incorporated cross-cultural adaptation process guidelines that are prescribed by Beaton et al. (2000) and/or guidelines prescribed by Guillemin et al. (1993). These guidelines target the maximum level of equivalency between the translated and original DASH versions while considering language and cultural differences. In their translation and adaptation methodology, all nine studies integrated forward and backward translation, held an expert committee to reach a consensus regarding the pre-fi nal translated version of the DASH and conducted field testing of the pre-fi nal version of the translated DASH with a number of clients with different upper extremity conditions. To illustrate the process of translating and adapting the DASH outcome measure questionnaire into different languages, the methodology of one cross-cultural adaptation process is used the Canadian French version of the DASH.

6 Cross-cultural adaptation of the disability of arm, shoulder and hand 183 Canadian French version of the DASH In their translations and adaptations of the DASH into Canadian French (Durand et al., 2005) the researchers followed the guidelines proposed by Beaton et al. (2000). First, two bilingual language persons whose native language was Canadian French translated the English version of the DASH into traditional Canadian French (Forward Translations). Second, following the forward translations, the synthesis of these two translations into a common translation took place. In the synthesis stage, the two translators along with two members of the research team reviewed and discussed the translated versions. Hence, they identified, discussed and resolved discrepancies between the two versions and reached a consensus and produced a new version of the Canadian French questionnaire. In addition, two professional translators whose mother language was English translated the new version produced in the synthesis stage back into English (Back Translations). These translators were independent, unaware of the DASH concept, and had no medical background. Following this stage, expert committee reviewers consolidated all versions (forward translations, translation synthesis, back translations) and developed a pre-fi nal Canadian French version. The expert committee included translators, health-care professionals and researchers. The role of this committee was to identify discrepancies between the two back translation versions, clarify any uncertainties related to previous stages and reach a consensus regarding the pre-fi nal Canadian French version. Finally, the last stage of the cross-cultural adaptation process was to test the pre-fi nal Canadian French version through conducting face-to-face interviews with Canadian French subjects who had various upper extremity conditions. The main goal of the interviews was to explore the meanings and clarity of each questionnaire item and response. As a consequence, the committee developed the fi nal Canadian French version of the DASH questionnaire. Lastly, this version was approved by the original developers of the DASH and officially used with Canadian French populations who have various upper extremity conditions. Known problems during the translation process Linguistic and cultural issues are of great concern in the cross cultural adaptation process. Upon review of the available studies, commonly encountered problems in the translation process were identified. Particular items are more difficult to translate than other items. For instance, Durand et al. (2005) indicated, when translating the DASH into Canadian French, that a problem occurred with item 8 (yard work). The back translator, who translated Canadian French back into English, had interpreted yard work as doing outdoor work, which could refer to different activities such as cleaning windows. Similarly, item 20 manage transportation needs was difficult to understand, unclear and less detailed (Durand et al., 2005; Lee et al., 2004; Themistocleous et al., 2006).

7 184 Alotaibi Moreover, same test items could be interpreted differently by subjects of the other culture (Durand et al., 2005). For example, the meaning of question 17 (recreation activities that require little effort such as playing cards or knitting) was interpreted in various ways by Canadian French clients. Some subjects stated that knitting is more difficult than playing cards while others mentioned that they have not ever engaged in knitting activities (Durand et al., 2005). In addition, the activities given as examples in item 18: recreation activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.) and item 19: recreation activities in which you move your arm freely (e.g., playing Frisbee, badminton, etc) were unknown, infrequently used, less applicable and/or inappropriate to the German, Brazilian Portuguese, Swedish, Chinese and Greek cultures (Atroshi et. al., 2000; Lee et al., 2004; Offenbacher et al., 2003; Orfale et al., 2005; Themistocleous et al., 2006). Another difficulty is that cultural norms can be a key factor in determining people s attitudes towards answering certain items in the DASH questionnaire including the Chinese, Taiwan, Italian, Armenian and Russian cultures (Lee et al., 2004 Liang et al., 2004; Padua et al., 2003; Yaghjyan et al., 2005). For example, in the Chinese culture, item 21 sexual activities was believed to be invading their cultural norms and thought of as less appropriate (Lee et al., 2004). Similarly, Italian patients were hesitant and expressed doubts when answering the same item, which caused some of them not to answer it (Padua et al., 2003). In addition, gender plays an important role in certain cultures, influencing choices of daily activity and what is considered as part of their lives. Hence, within the Armenian culture, cooking is believed to be a woman s task. Therefore, the majority of men, when administering the Armenian DASH, did not answer item 4 preparing a meal because cooking did not capture their activity of daily living and thus was considered less relevant (Yaghjyan et al., 2005). Besides considering the linguistic and cultural issues, technical issues can also have an impact on the process of translating and adapting outcome measures into a new language/culture. These technical issues, if not addressed properly, might influence the performance of the translated outcome measure and lead to misinterpretation of its fi ndings. For example, Durand et al. (2005) stated that some patients thought that they could answer the optional modules of the Canadian French DASH based on the status of their affected upper extremity. However, these patients forgot to follow the instructions at the beginning of the questionnaire (that they had to answer the questions regardless of which upper limb they used to perform the activity). The reason for that oversight was because there were no instructions given in the beginning of the optional modules (Durand et al., 2005).

8 Cross-cultural adaptation of the disability of arm, shoulder and hand 185 Proposed solutions to encountered problems The expert committee reviewers play a significant role in solving problems during the cross-cultural adaptation process. Also, contact with the developers of the original DASH outcome questionnaire is of great help in fi nding appropriate alternatives or solutions. As indicated by all the authors of the reviewed studies, most or all the encountered problems related to the translation process are categorized under linguistic, cultural and technical issues. Linguistic errors resulted from the forward and back translation process, such as the way yard work was translated as doing outdoor work in the Canadian French language as previously described. Consequently, the committee decided to translate it as taking care of the land, which reflected the intended meaning in the original DASH questionnaire. To resolve issues regarding clarity and understanding items within the translation process, the expert committee reviewers recommended including further details of translated items so that they would be more meaningful to clients from different cultures. For example, in the Greek version of the DASH, the expert committee reviewers thought that item 20: manage transportation needs required more detail to capture the daily activity of the Greek population. Therefore, the committee changed this item to ability to perform/prepare trips and daily transportations, which provided more clarification (Themistecleous et al., 2006). Some items in the original DASH questionnaire are supported by examples to clarify meanings. However, such activity examples are culture specific. For example, as mentioned, many Canadian French subjects didn t answer item 17: recreation activities that require little effort, such as playing cards or knitting because some perceived knitting and playing cards to have different degrees of difficulty and others mentioned that knitting is never practiced. In order to eliminate the confusion, the committee agreed to remove knitting from the list of activity examples (Durand et al., 2005). Similarly, when adapting the DASH into German, playing Frisbee was removed from the list of recreation activities because it is uncommon in Germany (Offenbacher et al., 2003). Different and sometimes opposing strategies have been identified to address differing cultural norms in relation to some items. As discussed, preparing a meal is viewed as a common task of both genders in the American/Canadian cultures, but as women s work in Armenia. Accordingly, the majority of Armenian men leave this question blank (Yaghjyan et al., 2005). The authors kept this item as is perhaps to maintain the integrity of the questionnaire items. In contrast, because the item about sexual activities was perceived as socially unacceptable, the expert committee decided to eliminate this question from the Chinese version of the DASH. The IWH, however, recommended retaining this item to preserve the integrity of the questionnaire and the committee agreed (Lee et al., 2004). Additionally, paying closer attention to the technical issues ensures successful translation and adaptation process. For example, to

9 186 Alotaibi overcome the problem of Canadian French clients forgetting to answer the DASH optional modules regardless of which hand was used to perform the activities, that expert committee decided to repeat the instructions at the beginning of the optional modules (Durand et al., 2005). Discussion The purpose of this review was to discuss issues pertaining to the translation and adaptation of the DASH into other languages. Successful cross-cultural adaptation process manifests itself by the use of proper methodology that ensures equivalency based on content between the original and translated outcome measures. It is crucial to note that this methodology does not replace testing the psychometric properties of the newly translated outcome measures. Rather, it facilitates and leads to sound psychometric properties of the newly translated outcome measures (Beaton et al., 2000). To support this point, following this rigorous methodology led to sound psychometric properties of all the translated DASH versions identified in this paper (Table 2). In addition, it is important to note that the developers of outcome measures or researchers involved in the cross-cultural adaptation process should be careful when constructing questionnaire items or when adapting items for use in other cultures. For example, one item can target two distinct features, which can cause confusion to the clients. Furthermore, beyond considering the linguistic and cultural issues within the cross-cultural adaptation process, it is essential to identify the technical issues and recognize their impact on the cross-cultural adaptation process. Unless these technical issues are well addressed, measuring the performance of clients will be jeopardized. The present review did not include all the translated versions of the DASH because they were written in languages other than English, did not discuss the qualitative issues regarding cross-cultural adaptation process or were not yet published. Thus, the issues discussed might not be comprehensive and possibly, further issues could be explored in future research. Also, this review noted that some articles did not elaborate fully on the cross-cultural adaptation process so that future researchers could benefit from the experience and build on it. Thus, it is highly recommended that future researchers involved in the cross-cultural adaptation process include the complete details of the process by addressing and discussing all issues. Implications for occupational therapy education, practice and research Implications of this systematic review include benefits to occupational therapy education, practice and research and thus are worth mentioning. Education is the fi rst and most influential channel that facilitates knowledge acquisition,

10 Cross-cultural adaptation of the disability of arm, shoulder and hand 187 TABLE 2: Psychometric properties of the cross-culturally adapted DASH outcome measure questionnaires Translated DASH Greek Brazilian Portuguese Armenian and Russian Canadian French Chinese (Hong Kong version) Chinese (Taiwanese version) Italian German (version 1) Swedish Reliability Cronbach s alpha = 0.96 Test-retest: Pearson s r = 0.91, p < Inter-observer reliability: Spearman s CC: 0.937, p < 0.01 Intra-observer reliability: Spearman s CC: 0.99, p < Cronbach s alpha = 0.96 (Armenian), 0.94 (Russian) Test retest: 0.99 (Armenian), p < 0.01, 0.95 (Russian), p < 0.01 Cronbach s alpha = 0.94 Cronbach s alpha = 0.94 Test retest: ICC(1,1) = 0.77, p = 0.77 Cronbach s alpha = 0.96 Test retest: ICC = 0.90 Cronbach s alpha: 0.90 Test retest: ICC = 0.89 Cronbach s alpha = 0.96 Test retest: Spearman s CC: 0.90, p < 0.01 Cronbach s alpha = 0.96 Test retest: ICC = 0.92 Validity Construct validity: Pearson s correlation between the DASH-GR and SF-36 total scores = 0.625, p < Construct validity: Spearman s correlation between the translated DASH and visual analog scale = 0.617, p < 0.01 Construct validity: Spearman s correlation between the Armenian and Russian DASH versions and SF- 36 physical functioning: 0.69 (Armenian), p < 0.01, 0.50 (Russian), p < 0.01 Content validity: It was evident by good completion of item response, adequate distribution of scores, and absence of ceiling and floor effect. Face validity: It was satisfactory with the mean endorsement score = 3.2, p = 0.73 Construct validity: Pearson s correlation between the translated DASH and SF- 36 physical functioning: 0.53, p < Construct validity: Pearson s correlation between the translated DASH and SF- 36 physical functioning: 0.41, p < 0.05 Construct validity: Spearman s correlation between the translated DASH and the upper extremity item score of the Stanford Health Assessment Questionnaire = 0.88, p < 0.01 Face and content validity: It was evident through good completeness of items and good distribution. Construct validity: Pearson s correlation between the translated DASH and SF-12 physical component = 0.51 (95% Confidence Interval)

11 188 Alotaibi promotes learning and affi rms the essence of cross-cultural use of assessments in occupational therapy. In educational settings, the meaning, issues and contributions of cross-cultural use of assessments in occupational therapy can be taught, thereby emphasizing the role of cross-cultural practice (e.g., the crosscultural use of assessments) and promoting occupational therapy internationally. The essence of cross-cultural use of assessments could also be promoted through presentations or workshops at international occupational therapy conferences or further publications. The cross-cultural use of assessments has potential to contribute to occupational therapy practice especially in countries that are just beginning to implement occupational therapy services. That will be a relevant contribution to their clinical environment because they will provide standardized outcome measures, thus supporting the recognition and appreciation of such services in these new countries/cultures. Occupational therapy researchers can also benefit from this discussion through identifying the sequential stages of cross-cultural adaptation of outcome measures, recognizing the elements and rationale of each stage and understanding the most common problems encountered and their resolution. Moreover, since the evaluation of measurement properties of a newly developed assessment tool is a continuing field of study (MacDermid, 2001), the translation and adaptation of standardized outcome measure questionnaires, such as the DASH, will introduce and support new areas of research. Having equivalent versions in different languages might also promote comparative studies from different countries (Durand et al., 2005), thus promoting cross-cultural communications among occupational therapy researchers that over time will serve to validate occupational therapy outcomes internationally. Finally, this review confi rms the value of qualitative research in evaluating the validity of translating standardized tests. Therefore, occupational therapy researchers are highly encouraged to incorporate this technique in future studies. Summary and conclusion The cross-cultural adaptation process of outcome measures, such as the DASH, is lengthy and challenging but rewarding. It addresses language translation and cultural adaptation of outcome measures, targeting semantic, idiomatic, experiential and conceptual equivalences between the translated outcome measure and the original one. To ensure equivalence based on content between the translated and original outcome measures, a systematic and standardized approach is required. Beaton et al (2000) proposed guidelines that appear to serve this purpose of this approach. Familiarity with problems and the proposed solutions identified in this review will also assist future translation and adaptation of occupational therapy evaluation tools for use in other countries with different cultures.

12 Cross-cultural adaptation of the disability of arm, shoulder and hand 189 Acknowledgement I want to express my appreciation and thanks to my committee members: Dr Gayle Hersch (Chair), Dr Kathlyn Reed, Dr Evelyn Andersson and Dr Gretchen Gemeinhardt for their continuous help and support. I also thank the staff and students at the school of Occupational Therapy, Texas Woman s University for their encouragement and support. References American Occupational Therapy Association (2002). Occupational therapy practice framework: domain and process. American Journal of Occupational Therapy 56: Atroshi I, Gummesson C, Andersson B, Dahlgren E, Johansson A (2000). The disability of the arm, shoulder and hand (DASH): reliability and validity of the Swedish version evaluated in 176 patients. Acta Orthopaedica Scandinavica 71: Beaton DE, Bombardier C, Guillemin F, Ferraz MB (2000). Guidelines for the process of crosscultural adaptation of self-report measures. Spine 25: Bourke-Taylor H, Hudson D (2005). Cultural differences: the experience of establishing an occupational therapy service in a developing community. Australian Occupational Therapy Journal 52: Clark F, Parham D, Carlson ME, Frank G, Jackson J, Pierce D, Wolfe R, Zemke R (1991). Occupational science: academic innovation the service of occupational therapy s future. American Journal of Occupational Therapy 45: Durand M, Vachon B, Hong QN, Loisel P (2005). The cross-cultural adaptation of the DASH questionnaire in Canadian French. Journal of Hand Therapy 18: Gandek B, Ware JE (1998). Overview of the SF-36 health survey and the international quality of life assessment (IQOLA) project. Journal of Clinical Epidemiology 51: Geisinger KF (1994). Cross-cultural normative assessment: translation and adaptation issues influencing the normative interpretation of assessment instruments. Psychological Assessment 6: Guillemin F, Bombardier C, Beaton DE (1993). Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. Journal of Clinical Epidemiology 46: Hudak PL, Amadio PC, Bombardier C, the Upper Extremity Collaborative Group (1996). Development of an upper extremity outcome measure: the DASH (disability of the arm, shoulder and hand). American Journal of Industrial Medicine 29: International Test Commission (2000). International Guidelines for Test Use. Surrey, England: Author. Johnson N (1998). Selecting outcomes measures for quality initiatives and other interventions. Formulary 33: Kielhofner G, Forsyth K (2001). Measurement properties of a client self-report for treatment planning and documenting therapy outcomes. Scandinavian Journal of Occupational Therapy 8: Law M, Philp I (2002). Systematically reviewing the evidence. In: Law M (ed). Evidence-Based Rehabilitation: A Guide to Practice (pp ). Thorofare, NJ: Slack. Lee EW, Lau JS, Chung M, Li AP, Lo SK (2004). Evaluation of the Chinese version of the Disability of the Arm, Shoulder and Hand (DASH-HKPWH): cross-cultural adaptation process, internal consistency and reliability study. Journal of Hand Therapy 17: Liang HW, Wang HK, Yao G, Horng YS, Hou SM (2004). Psychometric evaluation of the psychometric evaluation of the Taiwan version of the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Journal of the Formosan Medical Association 103:

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