Reliability and Validity of the Arabic Version of Shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (Quick-DASH) in Breast Cancer Survivors

Abstract

This study examined the psychometric properties of the Arabic Quick-Disability of the Arm, Shoulder, and Hand (QDASH-Ar) for breast cancer (BC) survivors. In this cross-sectional study, a convenient sample of 88 BC survivors was recruited and completed both the QDASH-Ar and Short Form-36 (SF-36) Arabic questionnaires. Internal consistency and test–retest reliability were assessed using Cronbach’s alpha and the two-way random intraclass correlation coefficient [ICC _(2.1)], respectively. Standard error of measurement (SEM) was used to calculate the minimal detectable change (MDC). Spearman correlation coefficients were used to test construct validity between QDASH-Ar and SF-36. The results demonstrated that QDASH-Ar had a Cronbach’s alpha of 0.86 and an ICC _(2.1) of 0.92. The scale’s SEM and MDC were 2.69 and 7.47, respectively. The correlation coefficients between the Quick-DASH score and the subscales of SF-36 ranged from −0.27 to −0.65, supporting the predefined hypotheses for construct validity. The discriminant validity was proven by the Quick-DASH total score between BC survivors with and without lymphedema (20.89 ± 12.78 vs. 33.63 ± 11.58, P < 0.01). In conclusion, QDASH-Ar demonstrated acceptable internal consistency, excellent test–retest reliability, and moderate to strong construct validity. Clinicians and researchers can use this valid instrument to assess and monitor upper extremity activity limitations and symptoms in BC survivors.

Main article text

INTRODUCTION

Breast cancer (BC) is the most common cancer among women worldwide ( Sung et al., 2021). It ranks first among Saudi women and accounts for 28.1% of all cancers. This number is expected to increase in the next few decades due to population growth and aging ( Alqahtani et al., 2020). More than 50% of BC survivors experience functional impairment in the upper extremities due to side effects of cancer itself and its treatment ( Hayes et al., 2012; Smoot et al., 2016). These impairments include pain, muscular tightness, weakness, limited mobility, altered movement patterns, loss of grip strength, and lymphedema. This often results in difficulty in dressing, washing, hair care, mopping and sweeping, and activities that require reaching ( Tsai et al., 2009; Smoot et al., 2016; Wang et al., 2016; Davies et al., 2018). Furthermore, these functional changes can lead to reduced ability to participate in daily living and community activities with subsequent poor quality of life (QOL) ( Hayes et al., 2012).

Many clinical and research studies have used valid and reliable patient-reported outcomes (PROMs) to identify and measure perceived functional impairments in BC survivors. Using PROM is convenient, easy to administer, cost-effective, facilitates communication between patients and their healthcare providers, and can identify changes in functions, abilities, and symptoms more efficiently. Furthermore, the use of PROMs improves the quality of healthcare by putting patients at the center of decision-making ( Coenen et al., 2013; Weldring and Smith, 2013). In response to this need, several PROMs have been validated into Arabic, such as the European Organization for Research and Treatment of Cancer (EORTC) Breast Cancer-Specific Quality of Life Questionnaire-23 items (QLQ-BR23), the Functional Assessment of Cancer Therapy-Breast (FACT-B), the EORTC Quality of Life Questionnaire, Version 3.0 (EORTC QLQ-C30), the Functional Assessment of Cancer Therapy-Breast plus Arm morbidity (FACT-B + 4), and the Functional Assessment of Cancer Therapy-General (FACT-G). These instruments demonstrate evidence of good psychometric properties in BC survivors and address functional capacity ( Alawadhi and Ohaeri, 2010; Huijer et al., 2013; Jassim and Whitford, 2013; Alawneh et al., 2016; Bener et al., 2017; Al-Hoqail et al., 2022). However, these instruments are lengthy which renders them difficult to use for clinical purposes. Additionally, the evaluation database to guide effectiveness (EDGE) Task Force of the oncology section of American physical therapy association’s (APTA) did not recommend these instruments to measure upper extremity function among BC survivors ( Miale et al., 2013).

The Disability of the Arm, Shoulder, and Hand (DASH) questionnaire was developed to measure disability and symptoms in people with various upper limb disorders ( Hudak et al., 1996). The DASH questionnaire is a reliable and valid instrument with excellent clinical utility in several conditions and the general population ( Hudak et al., 1996; Hunsaker et al., 2002; Rodrigues et al., 2015; Fonseca et al., 2019). DASH appears to be a very beneficial tool in the assessment of shoulder function after BC-related treatment ( Harrington et al., 2011; Koehler et al., 2018) and in BC-related lymphedema (BCRL) ( Omar et al., 2020; Guloglu et al., 2023). However, there were only a few studies concerning its psychometric properties in this population ( Beaton et al., 2001; Davies et al., 2013; Davies et al., 2015). Recently, the shorter Quick-DASH was developed (11-item questionnaire) to assess upper extremity disability and can be interchanged with DASH without loss of precision ( Beaton et al., 2005; Gummesson et al., 2006). Quick-DASH reduces respondents’ time, facilitates administration, and minimizes information loss ( Beaton et al., 2005; Mintken et al., 2009). Therefore, it is most suitable for use with BC survivors at risk of upper extremity disability ( LeBlanc et al., 2014; Xu et al., 2022).

The Arabic Quick-DASH (QDASH-Ar) is currently available in the official DASH outcome measure website ( http://www.dash.iwh.on.ca/) and a number of research studies in patients with upper extremity musculoskeletal disorders have shown sufficient internal consistency, test–retest reliability, and construct and structural validity ( Alotaibi, 2010; Alnahdi, 2021). However, there are no studies analyzing its psychometric properties among BC survivors. The purpose of this study is to determine the internal consistency, test–retest reliability, and measurement error of QDASH-Ar, as well as its construct validity, among BC participants. The Quick-DASH score was also compared between BC participants with and without lymphedema to determine its known-group validity.

MATERIALS AND METHODS

Study design

A cross-sectional design was used to evaluate the psychometric properties of the QDASH-Ar questionnaire in terms of internal consistency, test–retest reliability, and construct and discriminant validity among BC survivors.

Setting and participants

BC survivors who attended physical therapy department at two large tertiary hospitals in Riyadh were invited to enroll in this study between October 2021 and March 2023. The convenience sample included BC survivors aged ≥18 years, diagnosed with BC, completed adjuvant therapy (chemotherapy and/or radiotherapy), able to read, write, and understand the Arabic language, and willing to cooperate and complete the questionnaires. Exclusion criteria were recurrent metastases, or infection in the arms, cognitive impairment (Mini–Mental State Examination scores <23) based on medical record, pregnancy, chronic diseases, and/or surgeries in the upper extremity that affects upper limb function. The comparison group for discriminant validity included 33 participants who met the same inclusion and exclusion criteria in addition to unilateral BCRL defined as inter-limb differences ≥10% ( Omar et al., 2020). Approval for the present study was obtained from the research ethics committee and institutional review board of King Saud Medical City (Ref. No. 19/0906/IRB). Based on the principles stated in the Declaration of Helsinki, written informed consent was obtained from all participants.

To estimate a correlation coefficient ≥0.30, with an alpha of 0.05 and a power of 0.80, between the QDASH-Ar and Short Form-36 (SF-36) survey, a sample size of 84 BCRL participants was required ( Faul et al., 2009). Considering a dropout rate of 10%, the estimated sample size was increased to 95 participants. A sample size of 30 participants was determined to be the minimum required sample size for examining test–retest reliability and measurement error ( Terwee et al., 2012).

Outcome instrument and procedure

Certified lymphedema therapists approached the patients who attended the physical therapy clinic and invited them to take part in the study. Upon accepting, they signed informed consent. Demographic information and medical-related data were collected through a face-to-face interview with participants and checking their medical records. Each participant completed two self-report Arabic questionnaires: the Quick-DASH and SF-36 Health Survey. An interval of up to 7 days after the first application of the Arabic DASH was established to ensure clinical stability across BC participants ( n = 30).

Arabic version of Quick-DASH

Quick-DASH is a self-reported questionnaire designed for evaluating the symptoms and physical function in upper extremity disorders ( Beaton et al., 2005; Gummesson et al., 2006; Kennedy et al., 2013). The QDASH-Ar consists of 11 items about physical function (8 items) and symptoms (3 items asking about pain or abnormal sensations). Each item has 5 response categories, which are scored between 1 (no limitations) and 5 (extreme limitations). It provides a cumulative score on a 100 scale, with 100 reflecting greater disability ( Alotaibi, 2010; Alnahdi, 2021).

Arabic version of quality-of-life SF-36 (SF-36-Ar)

SF-36 is a generic measure quantifying two major health domains: physical component (PC) and mental component (MC). The PC consists of four domains: physical functioning (PF, 10 items), bodily pain (BP, 2 items), role limitations due to physical problems (RP, 4 items), and general health (GH, 5 items). The MC consists of four domains: role limitations due to emotional problems (RE, 3 items), mental health (MH, 5 items), social functioning (SF, 2 items), and vitality (VT, 4 items). The questionnaire has a single item about perception of change in GH status over a 1-year period. The total score of SF-36 ranges from 0 to 100, and a higher score indicates that participants have a better QOL ( Ware et al., 1993). The Arabic version of SF-36 has acceptable psychometric properties ( Hays et al., 1993; Coons et al., 1998).

Statistical analysis

Statistical analysis was performed using SPSS version 26.0 (SPSS Inc., Chicago, IL, USA), and normality was checked using the Kolmogorov–Smirnov normality test (significance >0.05). Descriptive statistics of the participants were reported using mean and standard deviation (SD) for continuous variables and frequency and percentage for categorical variables. The significance was set as P < 0.05.

Reliability

Internal consistency was analyzed by Cronbach’s alpha coefficient (α). An alpha finding of 0.7 is considered to represent a fair degree of internal consistency, 0.8 is considered good, and 0.9 would represent excellent internal consistency ( Raven et al., 2008). Item-to-total correlation analysis (ITC) and Cronbach’s alpha analysis with item deletion were also performed. An ITC value of >0.20 was considered satisfactory and Cronbach’s alpha after each item deletion would be expected to be below the total Cronbach’s alpha value ( DeVellis, 2016).

A two-way random intraclass correlation coefficient (ICC) was used to determine the test–retest reliability of QDASH-Ar. ICCs were interpreted as follows: “very strong” ICC > 0.90, “strong” ICC = 0.75-0.90, “moderate” ICC = 0.4-0.74, and “weak” ICC < 0.40 ( Lexell and Downham, 2005). Bland–Altman analysis was performed to determine within-participants variations and the limits of agreement (LOA). A scatter plot was then drawn depicting the difference between the test and retest Quick-DASH scores as the y axis and the mean of both scores as the x axis ( Bland and Altman, 2010). Standard error of measurement (SEM) was used to estimate the within-subjects variation of two measurements using the equation SEM = SD12 √(1 – ICC). Then, minimal detectable change (MDC) was determined to assess clinically important changes using the following formula: MDC ₉₅ = 1.96 × √2 × SEM ( Lexell and Downham, 2005; Koo and Li, 2016).

Validity

Correlations between QDASH-Ar and SF-36 were examined using Pearson correlation coefficient for normally distributed scores or Spearman correlation coefficient for non-normally distributed scores. The following hypotheses were examined to investigate construct validity: (1) the PC summary score of SF-36 and its PF, RP, and BP would exhibit a moderate to strong correlation ( r ≥ −0.4) with Quick-DASH; (2) the MC summary of SF-36 and its SF and VT would demonstrate a weak correlation with Quick-DASH; and (3) both MH and RE would exhibit no or little correlation with Quick-DASH. As recommended, a correlation of <0.20 indicates little or no correlation, 0.2-0.39 indicates a weak correlation, 0.40-0.59 indicates a moderate correlation, 0.60-0.79 indicates a strong correlation, and <80 indicates a very strong correlation ( Papageorgiou, 2022).

The known-groups validity is used to evaluate whether QDASH-Ar can differentiate between BC participants with and without lymphedema using the Mann–Whitney U test. It was hypothesized that participants with BCRL displayed significantly higher mean scores than those without lymphedema. The effect size (ES) was determined by dividing the difference in mean scores by the pooled SD and calculated based on Cohen’s guidelines where ES values between 0.50 and −0.80 were considered moderate and >0.80 large ( DaSilva et al., 2020; Md Yusof et al., 2021).

RESULTS

Participant characteristics

A total of 138 participants were screened for eligibility. Seventeen participants did not meet the inclusion criteria: infection ( n = 5), recurrent metastasis ( n = 8), and incomplete data ( n = 4). A total of 88 participants with BC were included in the final analysis, and 33 participants with BCRL for comparison to determine known-group validity. The two groups were comparable in sociodemographic and clinical characteristics ( Table 1).

Table 1:

Sociodemographic and clinical characteristics of the participants with BC ( n = 88) and BCRL ( n = 33).

	BC ( n = 88)	BCRL ( n = 33)
Age (mean ± SD) (years)	48.67 ± 7.13 a	48.54 ± 9.78
Marital status
Single	4 (4.55) b	0 (0)
Married	68 (77.27)	29 (87.88)
Widow	7 (7.95)	2 (6.06)
Divorced	9 (10.23)	2 (6.06)
Education level
Primary/secondary school	49 (55.70) b	18 (54.55)
College/university	39 (44.30)	15 (45.45)
Employment
Employed	30 (34.10) b	9 (27.30)
Unemployed/retired	58 (65.90)	24 (72.70)
Menopausal status
Pre-menopausal	28 (31.80) b	17 (51.52)
Peri-menopausal	29 (33.00)	5 (15.15%)
Post-menopausal	31 (35.20)	11 (33.33%)
BMI (kg/m 2) (mean ± SD)	30.56 ± 4.86 a	29.89 ± 3.40
Normal weight	12 (13.60) b	4 (12.12)
Overweight	26 (29.50)	11 (33.33)
Obese	50 (56.90)	18 (54.55)
Comorbidities
Yes	33 (37.50) b	15 (45.50)
No	55 (62.50)	18 (54.50)
Stage of cancer
I-II	29 (33.00) b	15 (45.50)
III-IV	59 (67.00)	18 (54.50)
Cancer site
Right	51 (58.00) b	17 (51.50)
Left	37 (42.00)	16 (48.50)
Lymphedema duration
<3 years	—	23 (69.70)
>3 years	—	10 (30.30)
Lymphedema staging
1	—	8 (24.20)
2	—	16 (48.50)
3	—	9 (27.30)
4	—	0 (0)

Data are presented as mean ± SD, or frequency (percentage).

Abbreviations: BC, breast cancer; BCRL, breast cancer-related lymphedema; BMI, body mass index; SD, standard deviation.

^aNon-significant differences ( P > 0.05) for Mann–Whitney U test.

^bNon-significant difference ( P > 0.05) for chi-squared test.

Reliability

A Cronbach’s alpha coefficient of 0.86 indicated good internal consistency reliability for Quick-DASH. Item-total correlations ranged from 0.35 (item 8: work activities) to 0.72 (item 9: pain). Cronbach’s alpha, when an item was deleted, did not increase by >0.1 for each item, indicating that all items were relevant to these participants ( Table 2).

Table 2:

Test–retest reliability of the Quick-DASH in BCRL participants.

	Cronbach’s α	Mean ± SD			Variability		Bland–Altman analysis
		Baseline	Retest	ICC (2,1) (95% CI)	SEM (95% CI)	MDC 95	d (SD)	LOA
Quick-DASH	0.86	22.11 ± 10.12	21.92 ± 8.94	0.92 (0.87 to 0.96)	2.69 (−6.87 to 12.25)	7.47	−0.20 (3.64)	−6.85 to 7.28

Abbreviations: BCRL, breast cancer-related lymphedema; CI, confidence interval; d, mean difference of the Quick-DASH score at baseline and retest; DASH, Disability of Arm, Shoulder, and Hand; ICC, intraclass coefficient correlation; ICC _(2,1), two-way random intraclass correlation coefficient; LOA, limits of agreement; MDC ₉₅, minimal detectable change from the 95% confidence interval level; SD, standard deviation; SEM, standard error of measurement.

Test–retest reliability results did not show any significant differences between two Quick-DASH measurements (22.11 ± 10.12 and 21.92 ± 8.94, P > 0.05); ICC _(2,1) was excellent [ICC = 0.92, 95% confidence interval (CI): 0.87-0.96].

The Quick-DASH score had a variability (SEM) of 2.69 and an MDC of 7.47. This means that an increase or a decrease in Quick-DASH that exceeds the MDC cannot be attributed to measurement error ( Table 3). Figure 1 illustrates the Bland–Altman plot of Quick-DASH. There was a 95% CI of −6.85 to 7.28 points between the lower and upper LOA of Quick-DASH, with 95% CIs of −8.72 to −5.16 and 5.54 to 9.11. As a result, the questionnaire has a random distribution, with a few points out of range.

Table 3:

Correlation coefficient of Quick-DASH with SF-36.

SF-36	Mean ± SD	Correlation coefficient
SF-36 summary scores
PCS	62.55 ± 19.27	−0.63 a
MCS	59.78 ± 16.04	−0.25 b
SF-36 subscales
Physical functioning	63.36 ± 27.43	−0.65 b
Role physical	65.90 ± 26.94	−0.53 b
Bodily pain	58.64 ± 22.13	−0.51 b
General health	62.21 ± 15.56	−0.31 a
Vitality	57.76 ± 17.67	−0.27 a
Social function	63.30 ± 15.27	−0.31 a
Role emotional	58.68 ± 39.89	−0.07 c
Mental health	59.36 ± 18.85	−0.19 c

Abbreviations: DASH, Disability of Arm, Shoulder, and Hand; MCS, mental component summary; PCS, physical component summary; SF-36, Short Form-36 questionnaire.

^aCorrelation is significant at P ≤ 0.05.

^bCorrelation is significant at P ≤ 0.01.

^cNon-significant correlation ( P > 0.05).

Figure 1:

Bland–Altman plot for Quick-DASH, with limits of agreement interval (blue line) of the mean difference (green line) between the two assessment times. Abbreviation: DASH, disability of the arm, shoulder, and hand.

Validity

The correlation coefficient between Quick-DASH and PC summary of SF-36 and its domains ranged from −0.51 to −0.65 which indicates a moderate to strong negative correlation. The strongest negative correlation was observed in PF ( r = −0.65) and PC summary ( r = −0.63), while RP ( r = −0.53) and BP ( r = −0.51) demonstrated a moderate negative correlation. The correlation between Quick-DASH and MC summary, SF, and VT was somewhat negative and weak ( r = −0.25, −0.26, and −0.25, respectively). The Quick-DASH was not relevant to RE ( r = −0.07) and MH ( r = −0.19), as shown in Table 3. Thus, all a priori hypotheses were accepted, confirming the validity of QDASH-Ar.

Considering the known-groups validity ( Table 4), results show that participants with BC who scored low on the Quick-DASH had a significant and substantial difference, giving an ES of −1.04 (95% CI: −1.46 to −0.62, P < 0.001). It was found that participants with BC had significantly lower disability (lower Quick-DASH scores) than those with BCRL in all items of Quick-DASH, with an ES ranging from moderate to large (−0.57 to −0.90), except in item 6: recreational (ES = −0.32, 95% CI: −0.72 to 0.08, P = 0.10), item 7: social activities (ES = −0.12, 95% CI: −0.52 to 0.28, P = 0.55), and item 11: sleep difficulty (ES = −0.33, 95% CI: −0.73 to 0.08, P = 0.14).

Table 4:

Comparison of Quick-DASH scores of BC and BCRL participants.

Variables	BC ( n = 88)	BCRL ( n = 33)	ES (95% CI)
Quick-DASH score	20.89 ± 12.78 a	33.63 ± 11.58	−1.04 (−1.46 to −0.62)
Item 1: open jar	1.75 ± 0.86 a	2.67 ± 1.47	−0.76 (−1.17 to −0.35)
Item 2: heavy chore	2.28 ± 0.80 a	2.88 ± 0.89	−0.71 (−1.11 to −0.29)
Item 3: carry bag	1.66 ± 0.80 a	2.15 ± 0.91	−0.57 (−0.97 to −0.16)
Item 4: wash back	1.77 ± 0.85 a	2.36 ± 1.03	−0.62 (−1.03 to −0.21)
Item 5: use knife	1.41 ± 0.67 a	2.27 ± 1.18	−0.90 (−1.31 to −0.47)
Item 6: recreational	1.80 ± 0.86 b	2.09 ± 0.94	−0.32 (−0.72 to 0.08)
Item 7: social activities	1.75 ± 0.78 b	1.85 ± 0.91	−0.12 (−0.52 to 0.28)
Item 8: work activities	1.94 ± 0.75 a	2.45 ± 0.67	−0.72 (−1.12 to −0.30)
Item 9: pain	2.00 ± 0.83 a	2.48 ± 0.66	−0.64 (−1.04 to −0.23)
Item 10: tingling	2.13 ± 0.91 a	2.64 ± 0.82	−0.59 (−0.99 to −0.18)
Item 11: sleep difficulty	1.70 ± 0.71 b	1.94 ± 0.75	−0.33 (−0.73 to 0.08)

Values presented as mean ± SD or as otherwise indicated.

Abbreviations: BC, breast cancer; BCRL, breast cancer-related lymphedema; CI, confidence interval; DASH, disability of the arm, shoulder, and hand; ES, effect size; SD, standard deviation.

^aSignificant at P ≤ 0.05.

^bNon-significant difference ( P > 0.05).

DISCUSSION

To our knowledge, this is the first study to examine the reliability and validity of the Arabic version of Quick-DASH when used among BC survivors. Quick-DASH demonstrated acceptable psychometric properties including good internal consistency, excellent test–retest reliability, and evidence of construct validity among BC survivors.

QDASH-Ar has an acceptable Cronbach’s alpha (0.86). Similar findings were found in other studies that examined the internal consistency of Quick-DASH for non-surgical upper limb musculoskeletal conditions with Cronbach’s alpha values ranging from 0.82 to 0.94 ( Imaeda et al., 2006; Wong et al., 2007; Fayad et al., 2009; Alotaibi, 2010; Dogan et al., 2011; Franchignoni et al., 2011; Ebrahimzadeh et al., 2015; Resnik and Borgia, 2015; Schønnemann and Eggers, 2016; Hammond et al., 2018; Cao et al., 2019; Alnahdi, 2021). Cronbach’s alpha values for Quick-DASH in this study were lower than those reported in previous studies that examined the internal consistency of DASH and Quick-DASH in BC survivors (0.87-0.97 and 0.93, respectively) ( Davies et al., 2013; LeBlanc et al., 2014; Davies et al., 2015). As a result of the present study, a Cronbach’s alpha of 0.86 indicates that the instrument is not redundant, is relatively short (11 items), does not require much time to complete (4 min), and has no missing data, making it appropriate for group comparison, but might not be adequate for individual comparison, since it is <0.90 ( Davis et al., 1999; Gummesson et al., 2006; Wong et al., 2007).

The test–retest reliability for Quick-DASH was excellent (ICC = 0.92) and thus met the cut-point for a positive rating (≥0.70). Furthermore, ICC 95% CIs have a lower limit (0.88) which exceeds the minimum ICC of 0.70 for 50 or more patients ( Terwee et al., 2007). In addition, Bland–Altman plots showed excellent agreement between the scores. These results are consistent with ICC values of original Quick-DASH (0.94) and published studies with ICCs ranging from 0.91 to 0.04 ( Fayad et al., 2009; Alotaibi, 2010; Dogan et al., 2011; Alnahdi, 2021). Although our ICC was slightly lower than that of Davis et al. (2013, 2015) (ICC = 0.97), it is higher than that of LeBlanc et al. (2014) (ICC = 0.78). The variability in ICC can be attributed to differences in patient population characteristics and the duration of questionnaire administration. LeBlanc et al. (2014) recruiting BC survivors suffering from shoulder pain with long intervals between questionnaire administrations (2 weeks) might result in pain fluctuation. In our study, Quick-DASH was administered at 1-week interval (5-7 days) to investigate test–retest reliability on the assumption that this interval would be short enough for the participants’ status to remain stable and long enough to ensure that they would not recall their first responses.

QDASH-Ar was evaluated for measurement variability as recommended by Lexell and Downham 2005. However, QDASH-Ar exhibits an SEM of 2.69 and an MDC of 7.47% which are lower than those reported in the literature (SEM = 3.85-6.73 and MDC = 11-17.2%) ( Hays et al., 1993; Ware et al., 1993; Ochi et al., 2015; Gabel et al., 2009; Mintken et al., 2009; Harrington et al., 2011).

As there is no “gold standard” for self-reported outcomes ( De Vet et al., 2011), we analyzed the correlations between Quick-DASH and SF-36 to test the construct validity, using correlation coefficients. Our results confirmed all predefined hypotheses about the expected correlations between Quick-DASH and SF-36 PC summary and its PF (−0.53 to −0.63). These observed correlations between Quick-DASH and measures of physical function have been reported previously in the literature. This indicates that the participant’s perception of PF in SF-36 is related to the experience on the corresponding total Quick-DASH which reflects conceptual alignment between these two scales as well as the ability of Quick-DASH to capture the physical function of the corresponding participant as reflected by this correlation between the scales ( Kennedy et al., 2013; Ebrahimzadeh et al., 2015; Schønnemann and Eggers, 2016; Hammond et al., 2018; Cao et al., 2019). Consistent with our predefined hypotheses, QDASH-Ar showed a moderate correlation with the SF-36 pain domain in the expected direction and magnitude similar to previous studies that reported a correlation pattern between Quick-DASH and measures of pain using the BP domain of SF-36 ( Kennedy et al., 2013; Ebrahimzadeh et al., 2015; Schønnemann and Eggers, 2016; Hammond et al., 2018; Cao et al., 2019). Furthermore, our results indicate a weak correlation with MC and its subdomain: SF and VT ranging from −0.25 to −0.31, with no relative correlation reported for MH and RE. These results corroborate with the Brazilian, Japanese, and Persian versions of Quick-DASH studies that found a weak correlation with the MCs of SF-36 ( Imaeda et al., 2006; Fayad et al., 2009; Ebrahimzadeh et al., 2015).

Furthermore, Quick-DASH is effective in discriminating between participants with BCRL and those without. It was found that BC participants displayed significantly lower mean scores than those with BCRL, which indicates a lower degree of activity limitation and symptoms among BC. This result is consistent with that of LeBlanc et al. (2014) who reported an effective discriminative ability of Quick-DASH between BC participants experiencing upper extremity pain secondary to frozen shoulder and/or arthralgia within the past 7 days and those who did not have pain.

Reaching all these hypotheses confirmed that QDASH-Ar is believed to have very good validity, and these results support the evidence of the construct and discriminant validity of QDASH-Ar. Therefore, QDASH-Ar is considered a positive measure of the upper limb disability of participants with BC.

A number of potential limitations of this study should be declared. Our sample was a non-random selection from two large hospitals, which may not represent the general patient population. However, this is a major tertiary referral center, providing care to a high volume of BC participants in the entire central provinces of Saudi Arabia. Another limitation is that we did not test the responsiveness of this instrument to intervention. Thus, future studies need to establish the QDASH-Ar responsiveness to upper extremity activity limitation and symptoms in BC participants secondary to different medical and physical therapy interventions. There is also a need to study the dimensionality of Quick-DASH. In contrast, different aspects of reliability and validity were considered and followed, including the recommended methods and preferred statistical analyses as described in the literature review with an overall good sample size ( Schønnemann and Eggers, 2016).

CONCLUSION

Our results suggest that QDASH-Ar had good internal consistency, excellent test–retest with acceptable measurement error, and moderate to strong construct validity. These results should be useful for clinicians and researchers using Quick-DASH as an outcome measure to assess and monitor upper extremity activity limitation and symptoms in BC survivors.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

ACKNOWLEDGMENTS

The authors extend their appreciation to the King Salman Center for Disability Research (funder ID: http://dx.doi.org/10.13039/501100019345) for funding this work through Research Group no. KSRG-2023-310.

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