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RehabMeasures Instrument

Disabilities of the Arm, Shoulder, and Hand Questionnaire

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Purpose

The DASH is designed to evaluate disorders and measure disability of the upper extremities, and monitor change or function over time.

Link to Instrument

Instrument Details

Acronym DASH

Area of Assessment

Upper Extremity Function

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Arthritis + Joint Conditions
  • Multiple Sclerosis
  • Pain Management

Key Descriptions

  • Developed jointly by the Institute for Work & Health and the American Academy of Orthopaedic Surgeons (AAOS).
  • The DASH was first published in 1996 and is now available in 2 shortened versions:
    1) QuickDASH
    2) QuickDASH-9
  • The DASH is a 30-item self-report questionnaire designed to assess musculoskeletal disorders of the upper limbs. It has two, 4-item, optional modules used to measure symptoms and function in athletes, artists, and workers who require a high level of function.
  • Scoring the DASH 30-item disability/symptom section:
    1) Item responses range from 1 (e.g. no difficulty, not at all, not limited, none, strongly disagree) to 5 (e.g. unable, extremely, unable, strongly agree)
  • Scoring the optional 2 4-item high performance sections:
    1) Add values of each response, then divide by 4, subtract 1 and multiply by 25: [((sum of values/4) - 1)*25]
    2) Optional modules should not be scored if items are missing
  • The DASH has been formally translated into 41 versions. There are 18 translations in progress.
  • More information, including a PDF of the DASH, can be found on the DASH website linked above.

Number of Items

30 or 34

Time to Administer

5-30 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Instrument Reviewers

Initially reviewed by Jill Smiley, MPH and Allison Todd in 5/2012; Updated by Franco Calabrese, SPT, Adam Fagan, SPT, and Patrick Galvin, SPT in 11/2012. Updated by Melissa M. Eden PT, DPT, OCS.

Body Part

Upper Extremity

ICF Domain

Body Structure
Body Function
Activity
Participation

Measurement Domain

Activities of Daily Living
Motor

Considerations

  • A shortform is also available (QuickDASH)

  • The DASH has been translated into 27 languages

Arthritis

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Standard Error of Measurement (SEM)

Osteoarthritis: (Vermeulen et al, 2009; n = 19, Primary Thumb Carpometacarpal Osteoarthritis; evaluated at 0, 3, 6 and 12 months, Osteoarthritis)

Analysis of the Change in DASH Score From Preoperative Clinical Evaluations

 

Mean

SD

SEM

Lower

Upper

DASH 0 to DASH 3

-14.93

9.63

2.27

-10.14

-19.72

DASH 0 to DASH 6

-20.54

14.58

3.26

-13.71

-27.36

DASH 0 to DASH 12

-20.83

20.09

4.49

-11.42

-30.23

*Paired differences of the DASH scores. DASH 0 is mean DASH score preoperative, DASH 3 is mean DASH score at 3 months, DASH 6 is mean DASH score at 6 months, and DASH 12 is mean DASH score at 12 months.

Normative Data

Osteoarthritis: (MacDermid et al., 2007; n = 122; mean age = 65.4 (8.1) years; time since surgery = 54.2 (23.1) months)

Arthroplasty of the carpometacarpal joint for osteoarthritis

 

Minimum

Maximum

Mean

SD

DASH

0

90.8

36.7

24.03

PRWHE

0

92

41.5

28.33

SF-36 Mental Component Summary

21.9

66.7

47.9

11.67

SF-36 Physical Component Summary

12.0

61.5

34.6

11.38

PRWHE: Patient-Rated Wrist Hand Evaluation; DASH: Disabilities of Arm, Shoulder, and Hand Questionnaire; SF-36: Short Form 36

 

Rheumatoid Arthritis: (Chiari-Grisar et al, 2006; n = 37; Function following finger joint arthroplasty in patients with rheumatoid arthritis; study performed in Austria; grip strength scores measured with a Martin vigorimeter, Rheumatoid Arthritis)

Instrument

Mean (SD)

Median

Min

Max

DASH (German version) score

44.52 (19.14)

44.2

5

82.5

HAQ score

1.12 (0.76)

1.06

0

2.88

DASH: Disabilities of Arm, Shoulder, and Hand Questionnaire; HAQ: Health Assessment Questionnaire

 

 

Test/Retest Reliability

Rheumatoid Arthritis: (Raven et al., 2008)

  • ICC = 0.97

 

Swedish Patients with Rheumatoid Arthritis: (Bilberg, Bremell, & Mannerkorpi, 2012; n = 67) 

  • ICC = 0.99 (95% CI, 0.98-0.99)

Internal Consistency

Rheumatoid Arthritis: (Raven et al., 2008)

  • Cronbach's alpha = 0.97

Construct Validity

Osteoarthritis: (MacDermid et al., 2007; n = 122; function following arthroplasty of the carpometacarpal joint of the hand for osteoarthritis; Osteoarthritis)

Correlations of the SF-36 component summary scores with PRWHE and DASH Scores

SF-36 Subscale

PRWHE

DASH

Physical Component Summary

-0.35

-0.49

Mental Component Summary

-0.45

-0.49

All correlations significant at the 0.01 level (2-tailed); SF-36: Short Form 36; PRWHE: Patient-Rated Wrist Hand Evaluation

 

Correlation between self-report function scores and measured impairments*

 

PRWHE total

DASH

Strength

 

 

Grip

-0.45**

-0.43**

Tripod pinch

-0.45**

-0.44**

Key pinch

-0.36**

-0.40**

Wrist flexion

-0.39**

-0.44**

Wrist extension

-0.39**

-0.37**

Dexterity

 

 

NK small objects

0.32**

0.30**

NK medium objects

0.39**

0.48**

NK large objects

0.44**

0.48**

Range of Motion

 

 

Wrist flexion

-0.26**

-0.23*

Wrist extension

-0.05

-0.07

Radial deviation

-0.15

-0.12

Ulnar deviation

-0.23*

-0.12

Pronation

-0.05

-0.03

Supination

0.00

-0.01

Thumb IP flexion

0.03

-0.08

Thumb MCP flexion

0.03

0.05

Thumb IP extension

0.12

0.06

Thumb MCP extension

-0.10

-0.02

Thumb CMC extension

-0.12

-0.11

Thumb abduction

0.01

0.03

Thumb opposition

0.11

0.10

Hand Span

-0.34**

-0.25**

*Impairments measured using the NK Hand Assessment System; **Correlation significant at 0.01 (2-tailed). *Correlation significant at 0.05 (2-tailed); PRWHE: Patient-Rated Wrist Hand Evaluation; DASH: Disabilities of Arm, Shoulder, Hand

 

Rheumatoid Arthritis: (Chiari-Grisar et al., 2006; n = 37; Function following finger joint arthroplasty in patients with rheumatoid arthritis; study performed in Austria, Rheumatoid Arthtitis)

SF-36 Subscale

Mean (SD)

Correlation to DASH (German version) 

Physical functioning

47.16 (24.17)

-0.73 (< 0.01)

Role-physical

32.43 (44.04)

-0.53 (< 0.01)

Bodily pain

43.92 (22.37)

-0.53 (< 0.01)

General health

51.41 (18.62)

-0.43 (< 0.01)

Vitality

46.08 (22.36)

-0.51 (< 0.001)

Social functioning

81.42 (21.77)

-0.35 (< 0.03)

Role-emotional

72.97 (41.45)

-0.31 (< 0.05)

Mental health

71.24 (18.66)

-0.57 (< 0.001)

SF-36: Short Form 36; DASH: Disabilities of Arm, Shoulder, Hand

 

Rheumatoid Arthritis: (Raven et al., 2008)

  • Correlation of DASH and other outcome measures: (Pearson correlation)
    • Health Assessment Questionnaire – r = 0.88
    • SF-36 – r = 0.70
    • Arthritis Impact Measurement Scale – r = 0.85
    • Disease Activity Score – r = 0.42
    • Grip Strength – r = 0.41-0.48
    • Visual Analog Scale – r = 0.60-0.65

 

Swedish Patients with Rheumatoid Arthritis: (Bilberg, Bremell, & Mannerkorpi, 2012; n = 67)

  • Correlation of DASH and other outcome measures: (Spearman correlation)
    • Health Assessment Questionnaire – r = 0.80
    • Active shoulder-arm motion – r = -0.38 to -0.50
    • Handgrip force – r = -0.46 to -0.59
    • Activity-Induced pain – r = 0.66
    • Disease Activity Score in 28 joints – r = 0.63

Floor/Ceiling Effects

Rheumatoid Arthritis: (Raven et al., 2008)

  • Floor effect: none
  • Ceiling effect: none

Joint Pain and Fractures

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Standard Error of Measurement (SEM)

Proximal Humeral Fractures: (Slobogean et al., 2010; n = 61, mean age = 69, Proximal Humeral Fractures)

  • Calculated using SEM = Standard Deviation of first outcome * square root (1-ICC)
  • SEM = 21.7 * square root (1 - 0.928) = 5.82

Minimal Detectable Change (MDC)

Proximal Humeral Fractures: (Slobogean et al., 2010; n = 61, mean age = 69, Proximal Humeral Fractures)

  • Calculated from MDC = 1.96 * SEM * (square root of 2)
  • MDC = 1.96 * 5.82 * (square root of 2) = 16.1

Minimally Clinically Important Difference (MCID)

Total Elbow Arthroplasty: (Angst et al., 2012; n = 65; 61.9 (13.0), Total Elbow Arthroplasty)

  • Standard Response Mean = 0.55, Effect Size = 0.20)

Pre-Operative and Post-Operative Change in UE Function: (Gummesson, Atroshi, & Ekdah, 2003; n = 109; patients had surgery for a variety of upper extermity conditions; assessed prior to surgery then again 6 to 21 months later; Swiss sample)

  • Patients (= 53) reporting "much better" or "much worse"
    • Mean Change = 19 (15 to 23) points
  • Patients (n = 21) reporting "somewhat better" or "somewhat worse"
    • Mean Change = 10 (7 to 14) points
  • Patients (n = 9) reporting "no change"
    • Mean change = -3 (-3 to 3.0) points

Normative Data

Elbow Disorders: (Angst et al., 2005; n = 79; mean age = 64.1 (13.3) years; time since surgery = 11.2 (3.0) years; Function following total elbow arthroplasty; Swiss sample)

Instrument

Mean (SD)

n

DASH

55.3 (23.2)

77

DASH function

51.1 (25.2)

77

DASH symptoms

66.1 (22.8)

79

SF-36 physical functioning

48.7 (28.4)

79

SF-36 role physical

45.1 (44.7)

76

SF-36 bodily pain

59.1 (27.5)

79

SF-36 general health

56.0 (25.7)

78

SF-36 vitality

48.4 (22.4)

78

SF-36 social functioning

80.7 (22.8)

79

SF-36 role emotional

74.8 (41.9)

72

SF-36 mental health

71.4 (20.6)

78

SF-36 physical component summary

37.2 (12.0)

75

SF-36 mental component summary

52.3 (11.5)

69

SF-36: Short Form 36; DASH: Disabilities of the Arm, Shoulder, and Hand Questionnaire

 

Wrist Disorders: (Imaeda et al., 2010; n = 117; adapted by the Japanese Society for Surgery of the Hand, Japanese sample, Wrist Disorders)

Score for PRWE, DASH-JSSH, and VAS:

Instrumental Scale

No.

Mean

SD

Median

Minimum

Maximum

DASH-JSSH

116

44.2

28.2

39.5

0(a)

100(b)

PRWE

112

58.7

24.3

61.5

5

99

VAS

111

59.3

24.3

60

6

100(b)

PRWE: Patient-Related Wrist Evaluation; DASH-JSSH: Disability/Symptom scale of the Japanese version of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnatire; VAS: Visual Analogue Scale for Pain (0-10 Scale); Maximum Health Status Scores (Ceiling)

Test/Retest Reliability

Proximal Humeral Fractures: (Slobogean et al., 2010; n = 61, mean age = 69)

  • Excellent test-retest reliability (ICC 2,1 = 0.928)

Instrument

ICC (95% CI)

Mean Difference

Limits of Agreement

EQ-5D

0.773 (0.604 to 0.875)

0.03 (0.00 to 0.06)

-0.18 to 0.24

HUI3

0.471 (0.184 to 0.686)

0.04 (-0.03 to 0.11)

-0.37 to 0.45

SF-6D

0.794 (0.634 to 0.889)

0.01 (-0.02 to 0.04)

-0.17 to 0.19

DASH

0.928 (0.860 to 0.963)

0.4 (-2.3 to 3.1)

-15.2 to 15.9

 

Total Elbow Arthroplasty: (Angst et al., 2012; n = 65; 61.9 (13.0))

  • Excellent test-retest reliability (ICC = 0.96)

Interrater/Intrarater Reliability

Proximal Humeral Fractures: (Slobogean et al., 2010; n = 61, mean age = 69, Proximal Humeral Fractures)

  • See Test-retest reliability in Proximal Humeral Fractures for format

Construct Validity

Proximal Humeral Fractures: (Slobogean et al., 2010; n = 61, mean age = 69, Proximal Humeral Fractures)

Spearman Correlations between Study Instruments

SF-12 PCS

0.49

1

       

DASH

-0.76

 

1

     

EQ-5D

0.53

0.73

-0.75

1

   

HUI3

0.38*

0.63

-0.58

0.63

1

 

SF-6D

0.45

0.83

-0.73

0.74

0.59

1

All correlations are significant to P < 0.01, except Self Function, HUI3 where P < 0.02.

 

Adhesive Capsulitis: (Staples, Forbes, Green, & Buchbinder, 2010)

  • SPADI – r = 0.55
  • Croft Index – r = 0.65
  • Visual Analog Scale – r = 0.31
  • Health Assessment Questionnaire – r = 0.54

 

Shoulder Arthroplasty (Switzerland, German-language): (Angst et al., 2004; n = 43)

  • SF-36 (PCS) – r = 0.67
  • SF-36 (MCS) – r = 0.06
  • SPADI – r = 0.93
  • pASES – r = 0.79
  • cASES – r = 0.59
  • Constant Shoulder – r = 0.82

Floor/Ceiling Effects

Elbow Disorders: (Angst et al., 2005)

DASH Floor and Ceiling Effects:

 

n

Minimum

Maximum

Floor, %

Ceiling, % 

DASH symptoms

79

12.5

100.0

0

6

DASH function

77

4.3

100.0

0

3

DASH

77

15.0

100.0

0

1

 

Proximal Humeral Fractures: (Slobogean et al., 2010; n = 61, mean age = 69)

  • No Floor effect established
  • Moderate: 7% ceiling effect

Responsiveness

Total Elbow Arthroplasty: (Angst et al., 2012; n = 65; 61.9 (13.0))

  • Effect Size = 0.56, Sensitivity = 0.59, Specificity = 0.71

 

Wrist Disorders: (Imaeda et al, 2010; n = 117; Japanese Version, adapted by the Japanese Society for Surgery of the Hand)

Standardized Response Means and Effect Size of PRWE and DASH

 

Total

 

 

Radius Fracture

 

 

Instrument Scale

No.

SRM

Effect Size

No.

SRM

Effect Size

DASH

50***

1.30

1.20

24***

2.13

2.05

PRWE

50***

1.55

1.92

24***

1.90

3.32

VAS

49***

1.75

2.23

24***

2.00

2.96

SRM, Standardized Response Means; PRWE, Patient-Related Wrist Evaluation; VAS, Visual Analogue Scale; ***Significant difference between the preoperative and postoperative median values (p < 0.001)

Musculoskeletal Conditions

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Standard Error of Measurement (SEM)

Adults with musculoskeletal upper extremity problems: (Schmitt & Di Fabio, 2004)

  • SEM = 5.22

Adults with musculoskeletal upper extremity problems: (Beaton et al., 2001)

  • SEM = 4.6

Proximal Humeral Fractures: (Slobogean et al., 2010; = 61, mean age = 69, Proximal Humeral Fractures)

  • Calculated using SEM = Standard Deviation of first outcome * square root (1-ICC)
  • SEM = 21.7 * square root (1 - 0.928) = 5.82

Minimal Detectable Change (MDC)

Adults with musculoskeletal upper extremity problems: (Schmitt & Di Fabio, 2004)

  • MDC90 = 12.2

Adults with musculoskeletal upper extremity problems: (Beaton et al., 2001)

  • MDC90 = 10.7
  • MDC95 = 12.75

Minimally Clinically Important Difference (MCID)

Adults with upper extremity musculoskeletal complaints undergoing surgery: (Angst, Schwyzer, Aeschlimann, Simmen, Goldhahn, 2011)

  • MCID = 10.2

Adults with musculoskeletal upper extremity problems: (Schmitt & Di Fabio, 2004)

  • MCID = 10.2

Test/Retest Reliability

Adults with musculoskeletal upper extremity problems: (Schmitt & Di Fabio, 2004)

  • ICC = 0.91

Adults with musculoskeletal upper extremity problems: (Beaton et al., 2001)

  • ICC = 0.96 (95% CI, 0.93-0.98)

Internal Consistency

Adults with upper extremity musculoskeletal complaints undergoing surgery: (Gummesson, Atroshi, & Ekdahl, 2003)

  • Cronbach's alpha = 0.92-0.97

Construct Validity

Convergent Validity:

Adults with musculoskeletal upper extremity problems: (Schmitt & Di Fabio, 2004)

  • Global Disability Rating – Spearman r = 0.67-0.71

Adults with musculoskeletal upper extremity problems: (Beaton et al., 2001)

  • SPADI pain – Pearson r = 0.79, Spearman r = 0.76
  • SPADI function – Pearson r = 0.85, Spearman r = 0.83

 

Discriminant Validity:

Adults with musculoskeletal upper extremity problems: (Beaton et al., 2001)

  • Participants who were working with their upper limb condition and were able to continue to work had a significantly lower disability than those unable to work (26.8 vs. 50.7, t = -7.51, p < 0.0001).
  • Similarly, the DASH was able to discriminate between those who could do everything they wanted to vs. those who could not (23.6 vs. 47.1, t = -5.81, p < 0.0001).

Floor/Ceiling Effects

Adults with musculoskeletal upper extremity problems: (Beaton et al., 2001)

  • Floor effect: none
  • Ceiling effect: only 1 of 200 in the sample scored 0 points

Multiple Sclerosis

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Internal Consistency

Adults with Multiple Sclerosis: (Cano, Barrett, Zajicek, & Hobart, 2011)  

  • Cronbach's alpha = 0.98

Non-Specific Patient Population

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Standard Error of Measurement (SEM)

Intercollegiate Athletes: (Hsu et al., 2010; n = 321; mean age 19.4 (17.6-22.6) years; Pre-competition physical)

  • 3.61 (Calculated from MDC = 1.96 x SEM x square root of 2; 10 = 1.96 x SEM x square root of 2)

Minimal Detectable Change (MDC)

Intercollegiate Athletes: (Hsu et al., 2010; n = 321; mean age 19.4 (17.6-22.6) years; Pre-competition physical)

  • MDC = 10

Minimally Clinically Important Difference (MCID)

Intercollegiate Athletes: (Hsu et al., 2010; n = 321; mean age 19.4 (17.6-22.6) years; Pre-competition physical)

Test/Retest Reliability

Overhead Athletes: (Alberta et al., 2010; n = 252 mean age = 23.7)

  • Adequate test-retest reliability (ICC = 0.536)

Internal Consistency

General Population: (Hunsaker, Cioffi, Amadio, Wright, & Caughlin, 2002)

  • Cronbach's alpha = 0.94-0.98

Floor/Ceiling Effects

Intercollegiate Athletes: (Hsu et al., 2010, Intercollegiate Athletes)

 

N

Minimum

Maximum

Floor %

Ceiling %

DASH

321

0

100

0

65.11

Chronic Pain

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Criterion Validity (Predictive/Concurrent)

Neck Pain: (Mehta et al., 2010; n = 66, mean age= 40.6 (14.2))

  • Both versions of the DASH showed high correlation (0.82-0.84) with the NDI and moderate correlation with the CSOQ and VAS.

Correlation Between Self-Report Measures

 

CSOQ Neck Pain

CSOQ Shoulder and Arm Pain

CSOQ Physical Symptom

CSOQ Functional Disability

CSOQ Psychological Distress

VAS

DASH

0.61*

0.55*

0.67*

0.58*

0.56*

0.55*

*Correlation is significant at the 0.01 level (2-tailed); CSOQ= Cervical spine outcome questionnaire; VAS= Visual Analog Scale

Construct Validity

Neck Pain: (Huisstede et al., 2009; n = 679; 41.0 (23.0))

 

SF-12 Physical Component

SF-12 Mental Component

Severity

 

Correlation

Correlation

Correlation

S-A-H

0.62

0.15

0.55

N-S-A-H

0.61

0.16

0.52

N-S-A-H

0.63

0.19

0.5

N

0.62

0.27

0.44

S-A-H- only

0.61

0.1

0.56

N-only

0.57

0.33

0.44

Responsiveness

Neck Pain: (Huisstede et al., 2009; n = 679; 41.0 (23.0))

  • DASH was considered acceptable for each (sub)group
  • The responsiveness ratio was higher in the S-A-H–only group (1.92) than in the N–only group (1.38)

 

Responsiveness Ratio

S-A-H Improved

2.01

S-A-H Stable

 

N-S-A-H Improved

1.91

N-S-A-H Stable

 

N-S Improved

2.04

N-S Stable

 

N Improved

1.85

N Stable

 

S-A-H Only Improved

1.92

S-A-H Only Stable

 

N-Only Improved

1.38

N-Only Stable  

Bibliography

Alberta, F. G., El Attrache, N. S., et al. (2010). "The development and validation of a functional assessment tool for the upper extremity in the overhead athlete." Am J Sports Med 38(5): 903-911. Find it on PubMed

Angst, F., Goldhahn, J., et al. (2012). "Responsiveness of five outcome measurement instruments in total elbow arthroplasty." Arthritis Care Res (Hoboken) 64(11): 1749-1755. Find it on PubMed

Angst, F., John, M., et al. (2005). "Comprehensive assessment of clinical outcome and quality of life after total elbow arthroplasty." Arthritis Rheum 53(1): 73-82. Find it on PubMed

Chiari-Grisar, C., Koller, U., et al. (2006). "Performance of the disabilities of the arm, shoulder and hand outcome questionnaire and the Moberg picking up test in patients with finger joint arthroplasty." Arch Phys Med Rehabil 87(2): 203-206. Find it on PubMed

Dupeyron, A., Gelis, A., et al. (2010). "Heterogeneous assessment of shoulder disorders: validation of the Standardized Index of Shoulder Function." J Rehabil Med 42(10): 967-972. Find it on PubMed

Gummesson, C., Atroshi, I., et al. (2003). "The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery." BMC Musculoskelet Disord 4(11): 11. Find it on PubMed

Hsu, J. E., Nacke, E., et al. (2010). "The Disabilities of the Arm, Shoulder, and Hand questionnaire in intercollegiate athletes: validity limited by ceiling effect." J Shoulder Elbow Surg 19(3): 349-354. Find it on PubMed

Huisstede, B. M., Feleus, A., et al. (2009). "Is the disability of arm, shoulder, and hand questionnaire (DASH) also valid and responsive in patients with neck complaints." Spine (Phila Pa 1976) 34(4): E130-138. Find it on PubMed

Imaeda, T., Uchiyama, S., et al. (2010). "Reliability, validity, and responsiveness of the Japanese version of the Patient-Rated Wrist Evaluation." J Orthop Sci 15(4): 509-517. Find it on PubMed

MacDermid, J. C., Wessel, J., et al. (2007). "Validity of self-report measures of pain and disability for persons who have undergone arthroplasty for osteoarthritis of the carpometacarpal joint of the hand." Osteoarthritis Cartilage 15(5): 524-530. Find it on PubMed

Mehta, S., Macdermid, J. C., et al. (2010). "Concurrent validation of the DASH and the QuickDASH in comparison to neck-specific scales in patients with neck pain." Spine (Phila Pa 1976) 35(24): 2150-2156. Find it on PubMed

Slobogean, G. P., Noonan, V. K., et al. (2010). "The reliability and validity of the Disabilities of Arm, Shoulder, and Hand, EuroQol-5D, Health Utilities Index, and Short Form-6D outcome instruments in patients with proximal humeral fractures." J Shoulder Elbow Surg 19(3): 342-348. Find it on PubMed

Vermeulen, G. M., Brink, S. M., et al. (2009). "Ligament reconstruction arthroplasty for primary thumb carpometacarpal osteoarthritis (weilby technique): prospective cohort study." J Hand Surg Am 34(8): 1393-1401. Find it on PubMed

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