LETTERS TO THE EDITOR
Letter Regarding Outcome Reporting for Brachial Plexus Reconstruction To the Editor: We read with interest your recent article by Dy et al.1 We commend the authors for their excellent review of outcome reporting after brachial plexus injury (BPI) and linking these findings to the challenge of assessing people with such a heterogeneous, unilateral condition. We concur with Dy et al that no one tool can capture all aspects of the impact of BPI on the individual and that a battery of measures is required. Other similarly devastating but uncommon diagnoses, such as upper limb amputation2 and Duchenne muscular dystrophy,3 have addressed these same issues by developing a core set of measures with proven psychometric properties using a consensus-based approach. When gaps have been identified, groups of clinicians have worked together across multiple sites to psychometrically evaluate existing measures or developed new diagnosis-specific measures. If widely accepted diagnosis-specific outcome measures are not available, alternatives are used that on the surface may appear to have face validity. However, on closer examination a number of issues may arise. For example, the Disabilities of the Shoulder, Arm, and Hand questionnaire (DASH),4 which is increasingly being reported in the BPI literature, asks respondents how they perform activities regardless of which limb or strategy is used. Consequently, the DASH does not discriminate between injury to the dominant or nondominant limb, so the same injury to 2 different people may result in large scoring differences based on dominance. Furthermore, because scores are not injured-limb specific, clinicians are not necessarily able to determine whether change scores are a result of recovery or compensation including change of dominance. In addition, a recent scoping review of the DASH raised significant questions as to what the DASH is measuring.5 People with less functionally disabling injury such as wrist arthritis or de Quervain tendinitis report similarly high DASH scores as people with severe functional loss (eg, BPI, upper limb amputation, and upper limb transplantation). Despite large differences in day-to-day upper-limb use, it appears that the DASH has limited capacity to differentiate between levels of severity and across
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Ó 2015 ASSH
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Published by Elsevier, Inc. All rights reserved.
diagnostic groups.5 Although difficult and timeconsuming to achieve, acceptance of a core set of measures developed using a consensus approach is essential to allow greater comparison of outcomes and evaluate the multitude of treatment options. Bridget Hill*† Gavin Williams, PhD† John Olver, MBBS, MD† Andrea Bialocerkowski, PhD* *Menzies Health Institute Queensland, Australia †Epworth Monash Rehabilitation Medicine Unit Epworth HealthCare Melbourne, Victoria, Australia http://dx.doi.org/10.1016/j.jhsa.2015.03.037 REFERENCES 1. Dy CJ, Garg R, Lee SK, Tow P, Mancuso CA, Wolfe SW. A systematic review of outcomes reporting for brachial plexus reconstruction. J Hand Surg Am. 2015;40(2):308e313. 2. Kohler F, Cieza A, Stucki G, et al. Developing core sets for persons following amputation based on the International Classification of Functioning, Disability and Health as a way to specify functioning. Prosthet Orthot Int. 2009;33(2):117e129. 3. Mercuri E, McDonald C, Mayhew A, et al. International workshop on assessment of upper limb function in Duchenne Muscular Dystrophy. Rome, 15-16 February 2012. Neuromuscul Disord. 2012;22(11):1025e1028. 4. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder, and hand). [Corrected]. Am J Ind Med. 1996;29(6):602e608. 5. Baltzer H, Novak CB, McCabe SJ. A scoping review of Disabilities of the Arm, Shoulder, and Hand scores for hand and wrist conditions. J Hand Surg Am. 2014;39(12):2472e2480.
In Reply: We thank the letter writers for their interest in our article. We agree that the task of measuring recovery after treatment of brachial plexus injuries (BPI) requires a multifaceted approach. No individual parameter can reflect the enormity of the impact of BPI on each patient’s life, given the broad physical and psychological components of the injury. Although we agree with the letter writers that the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) has distinct limitations in specifically capturing functional recovery of the affected limb after BPI, our experience
Letter Regarding Outcome Reporting for Brachial Plexus Reconstruction To the Editor: We read with interest your recent article by Dy et al.1 We commend the authors for their excellent review of outcome reporting after brachial plexus injury (BPI) and linking these findings to the challenge of assessing people with such a heterogeneous, unilateral condition. We concur with Dy et al that no one tool can capture all aspects of the impact of BPI on the individual and that a battery of measures is required. Other similarly devastating but uncommon diagnoses, such as upper limb amputation2 and Duchenne muscular dystrophy,3 have addressed these same issues by developing a core set of measures with proven psychometric properties using a consensus-based approach. When gaps have been identified, groups of clinicians have worked together across multiple sites to psychometrically evaluate existing measures or developed new diagnosis-specific measures. If widely accepted diagnosis-specific outcome measures are not available, alternatives are used that on the surface may appear to have face validity. However, on closer examination a number of issues may arise. For example, the Disabilities of the Shoulder, Arm, and Hand questionnaire (DASH),4 which is increasingly being reported in the BPI literature, asks respondents how they perform activities regardless of which limb or strategy is used. Consequently, the DASH does not discriminate between injury to the dominant or nondominant limb, so the same injury to 2 different people may result in large scoring differences based on dominance. Furthermore, because scores are not injured-limb specific, clinicians are not necessarily able to determine whether change scores are a result of recovery or compensation including change of dominance. In addition, a recent scoping review of the DASH raised significant questions as to what the DASH is measuring.5 People with less functionally disabling injury such as wrist arthritis or de Quervain tendinitis report similarly high DASH scores as people with severe functional loss (eg, BPI, upper limb amputation, and upper limb transplantation). Despite large differences in day-to-day upper-limb use, it appears that the DASH has limited capacity to differentiate between levels of severity and across
1504
r
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
diagnostic groups.5 Although difficult and timeconsuming to achieve, acceptance of a core set of measures developed using a consensus approach is essential to allow greater comparison of outcomes and evaluate the multitude of treatment options. Bridget Hill*† Gavin Williams, PhD† John Olver, MBBS, MD† Andrea Bialocerkowski, PhD* *Menzies Health Institute Queensland, Australia †Epworth Monash Rehabilitation Medicine Unit Epworth HealthCare Melbourne, Victoria, Australia http://dx.doi.org/10.1016/j.jhsa.2015.03.037 REFERENCES 1. Dy CJ, Garg R, Lee SK, Tow P, Mancuso CA, Wolfe SW. A systematic review of outcomes reporting for brachial plexus reconstruction. J Hand Surg Am. 2015;40(2):308e313. 2. Kohler F, Cieza A, Stucki G, et al. Developing core sets for persons following amputation based on the International Classification of Functioning, Disability and Health as a way to specify functioning. Prosthet Orthot Int. 2009;33(2):117e129. 3. Mercuri E, McDonald C, Mayhew A, et al. International workshop on assessment of upper limb function in Duchenne Muscular Dystrophy. Rome, 15-16 February 2012. Neuromuscul Disord. 2012;22(11):1025e1028. 4. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder, and hand). [Corrected]. Am J Ind Med. 1996;29(6):602e608. 5. Baltzer H, Novak CB, McCabe SJ. A scoping review of Disabilities of the Arm, Shoulder, and Hand scores for hand and wrist conditions. J Hand Surg Am. 2014;39(12):2472e2480.
In Reply: We thank the letter writers for their interest in our article. We agree that the task of measuring recovery after treatment of brachial plexus injuries (BPI) requires a multifaceted approach. No individual parameter can reflect the enormity of the impact of BPI on each patient’s life, given the broad physical and psychological components of the injury. Although we agree with the letter writers that the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) has distinct limitations in specifically capturing functional recovery of the affected limb after BPI, our experience
