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Is the Disabilities of the Arm, Shoulder, Hand Questionnaire (DASH) an accurate measure of Outcomes post rotator cuff repair?

Timothy J.Chaffman
Gary D. Harner
Holly Jo Harvey
Jeffrey D. Litishin
Monica L.Miller
Timothy W.Miller
John W. O’Halloran
Laura M. Rothermel

April 24, 2009

ABSTRACT

Purpose: The purpose of this systematic review was to determine if the disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) is an accurate measure of outcomes post rotator cuff repair.

Methods: A systematic review was performed to examine whether the disabilities of the Arm, Shoulder and Hand (DASH) outcome measure tool is effective in measuring post-operative rotator cuff repair outcomes. Nineteen studies were found in our search. Based on our inclusion criteria, ten were included in our review. In order to rate these articles, we elected to use the Physiotherapy Evidence Database (PEDro) scale.

Results: The majority of the studies we reviewed were of high quality and scored 5 or higher on the PEDro scale. The articles included in our review did not report psychometrics, such as reliability and validity, for the DASH outcome measure. The psychometrics for the DASH were completed in previous studies.

Discussion: Based on the reported studies, we deducted that the DASH is a valid tool and it can detect small and large changes of disability over time after surgery.

Conclusion: There is evidence that supports the DASH questionnaire as a valid and accurate instrument in assessing outcomes post rotator cuff repair.

OBJECTIVE

The Purpose of this systematic review was to determine if the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) is an accurate measure of outcomes post rotator cuff repair.

INTRODUCTION

What’s New?

In recent years, the measurement of clinical outcomes has become an increasingly important part of the practice of physical therapy.  Patient-centered outcome assessments have been stressed, shifting the manner in which effectiveness of care is judged.  Instead of purely clinician based opinion, patient based views are valued.  The use of clinical outcomes to manage clinical care has been emphasized 6  It is important for physical therapists to record clinical outcomes that result from the treatment methods and interventions in order to evaluate their effectiveness and quality of care.

The focus of clinical outcomes assessment is currently based on exploring what the patient experiences and values after medical interventions and treatments.  Outcomes research links the care people receive to clinical outcomes that are important for analyzing and improving the quality of patient care.18  Using patient self-reported scales to measure functional limitations and disability enables health professionals to assess the effect of health care services on the patient’s health-related quality of life.  These measures related to function may include mental function, physical function, and limitations in social role or function, all of which may impact the overall health status of the patient.27

Physical therapists treat patients with a wide variety of conditions affecting different parts of the body.  Many outcome measurements exists that reference different body parts and measure the end result of treatment and its impact on a patient.  Shoulder injuries involving the rotator cuff are a common pathological condition for which patients seek treatment by physical therapists and physicians.  Often, surgical repair is necessary.  Determining the outcome of the orthopedic surgical procedures, such as rotator cuff repair, is essential to define the impact of the condition and to determine optimal treatment.  The outcome assessment performed should use the relevant and appropriate tools and methodology.26  One outcome measure that is commonly used by providers to assess the results of rotator cuff repair is the Disability of the Arm, Shoulder and Hand (DASH) upper extremity outcome measure.

History

The Disability of the Arm, Shoulder and Hand (DASH) upper extremity outcome measure was developed by the American Academy of Orthopedic Surgeons and Institute for Work & Health (IWH).  It was designed to assess the functional status and symptoms of clients with upper extremity conditions.13 The DASH contains 30 items, most of which describe the amount of difficulty the patient faces while performing various physical tasks due to arm, shoulder or hand problems (21 items).  It also documents the severity of each of the symptoms of pain, activity-related pain, tingling, stiffness and weakness (five items).  In addition, the DASH describes issues that affect social activities, work, sleep and psychological impact (four items). The DASH also contains two four-item optional components that are scored separately from the 30-item DASH. These components involve the patient’s ability to perform sports and/or to play a musical instrument (sport/music scale) or the ability to work (work scale). These optional components are meant for athletes, musicians or workers whose occupations demand increased levels of physical performance. Each item of the DASH 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 obtained.  The assigned values for all the completed responses are summed and averaged, and then this value is transformed to 100 by subtracting 1 and multiplying by 25, in order to compare to other measures that us 0 to 100 scales.  The same method is used with the optional component, provided that all the questions are answered.3

The DASH upper extremity questionnaire has been shown to be an exemplary outcome measure, which can be utilized in the clinical environment.  It is standardized, easy to administer, applies to a range of conditions, involves the patient in the evaluation process, focuses on the functional status of the patients and reports the patient status at the time of assessment.  The DASH can also be used to monitor patient status over time and measure the therapeutic effectiveness of a particular method of intervention.  Because of this, the DASH plays an important role in confirming evidence-based practice.  It is a tool that can be used to monitor the patient’s outcome across a continuum of care, enable evidence of the therapeutic outcome of services, supports the credibility of health professions and also enhances the quality of care.  The DASH has become very popular and has been translated to many different languages.2

Background

Rotator cuff disorders are widespread and it is possible that there will be a dramatic increase in the individuals with rotator cuff pathologies in the future. 26 Full thickness rotator cuff tears are one of the most common reasons for shoulder surgery.  The clinical outcomes of rotator cuff repair have been promising, but there is still debate on the exact indications, surgical techniques, and repair outcomes.21 As different repair techniques emerge, it is important to determine outcomes in order to achieve the most beneficial results for patients with a rotator cuff tear.  Therefore, it is essential to evaluate outcome tools that may help to improve the evaluation of interventions that are employed in the treatment of rotator cuff disorders.  With this information, the optimal treatment may be determined.

The rationale of this study was to conduct a systemic review of literature to determine if the DASH is an effective tool for measuring the outcome of surgical repair of the rotator cuff.  The goal is to discuss issues pertaining to the usefulness of the DASH in measuring functional outcomes of surgical rotator cuff repair:  Is the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire an accurate measure of post rotator cuff repair outcomes?

METHODS

A systematic review was performed to examine whether the disabilities of the Arm, Shoulder and Hand (DASH) outcome measure tool is effective in measuring post-operative rotator cuff repair outcomes.

Literature Review

In February 2009 a search of the following databases was performed: Medline: (1996-2009), CINAHL: (1996-2009), Pubmed (1996-2009).  Combinations of the following search terms were used for all databases: DASH, shoulder, surgery, rotator cuff repair, rotator cuff tear, measurements, outcomes, physiotherapy, and physical therapy.  The publication details of the randomized controlled trials (RCT’s) involving rotator cuff repair DASH outcomes were obtained.  References listed in these papers were also examined for additional studies as needed. 

Use of the key words in the database searches yielded nineteen articles published between 1996 and February 2009.  Our selection criteria were articles written in English, RCT’s and rotator cuff post-operative outcomes evaluated.  Exclusion criteria were those studies that involved outcome measures that did not include the DASH.  Also excluded were non RCT studies.  Eight articles were immediately excluded because they did not meet our inclusion criteria.  One article that was included was retained secondary due to its linking the DASH outcome measure to the International Classification of Functioning, Disability, and Health (ICF) framework.  The remaining ten articles underwent a quality scoring by the authors (JL, MM, TM, TC, LR, and HK).  PEDro scales were used to score the researched articles.

Article Review

As stated previously, the Physiotherapy Evidence Database scale (PEDro) was chosen to measure the methodological quality of ten articles with the common topic being functional assessment scales of the post-operative shoulder.  To ensure inter-rater reliability, two or more raters graded each of the ten articles.  Each article was read independently and then rated and given a score based on the criteria of the PEDro scale.  If at all possible, the same raters were used to read and score each article.  If conflicting scores were recorded for a given criterion point, the score most often recorded was used as a tiebreaker.

RESULTS

PEDro Scale

Nineteen studies were found in our search.  Based on our inclusion criteria, ten were included in our review.  In order to rate these articles, we elected to use the Physiotherapy Evidence Database (PEDro) scale.  The majority of the studies we reviewed were of high quality and score 5 or higher on the PEDro scale.28

PEDro Scale

1.  Eligibility criteria were specified. No/Yes
2.  Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received). No/Yes
3.  Allocation was concealed. No/Yes
4.  The Groups were similar at baseline regarding the most important prognostic indicators. No/Yes
5.  There was blinding of all subjects. No/Yes
6.  There was blinding of all therapists who administered the therapy. No/Yes
7.  There was blinding of assessors who measured at least one key outcome. No/Yes
8.  Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups. No/Yes
9.  All subjects for whom outcome measures were available received the treatment or control condition as allocated or, were this was not the case, data for at least one key outcome was analyzed by “intention to treat”. No/Yes
10.  The results of between-group statistical comparisons  are reported for at least one key outcome. No/Yes
11.  The study provides both point measures and measures of variability for at least one key outcome. No/Yes

 

Study

PEDro Criterion Score

1

2

3

4

5

6

7

8

9

10

11

Total

Level

MacDermid JC (2)

Y

N

N

Y

N

N

N

Y

Y

Y

Y

5

lb

Milano G (3)

Y

Y

Y

Y

N

N

N

Y

Y

Y

Y

7

lb

Allom R (4)

Y

N

N

Y

N

N

N

Y

Y

Y

Y

5

lb

Namdari S (5)

Y

N

N

Y

N

N

N

Y

Y

Y

Y

5

4

Skutek M (10)

N

N

N

Y

N

N

N

Y

Y

Y

Y

5

lb

Kennedy CA(11)

Y

N

N

Y

N

N

N

Y

Y

Y

Y

5

2b

Henn RF (13)

Y

N

N

Y

N

N

N

Y

Y

Y

Y

5

1b

Tashjian A (14)

Y

N

N

Y

N

N

N

Y

Y

Y

Y

4

1b

Beaton DE (16)

Y

N

N

Y

N

N

N

Y

N

Y

Y

4

1b

Getahun TY (19)

Y

N

N

Y

N

Y

N

Y

N

Y

Y

6

1b

 

Author

Study Design/Level of Evidence

Age and Gender

Primary Diagnosis

Sample Size

Inclusion/Exclusion

Results

Allom

Prospective Cohort Study PEDro: 5/10

205 Women 167 men Age: Mean 56

 

Rotator cuff Repairs: 248 with Subacromial decompression w/o rotator cuff Repair and all repairs of the rotator cuff in 124 patients

 

372 subjects

Inclusions:
Patients with subacromial Decompression w/o Rotator cuff  Repair, arthroscopic Repairs and Open rotator cuff repairs

Exclusion:
Not stated

Preoperative: DASH=40.73 To 47.27 P<0.27 Follow up (6 mo.) 53.6 to 68.2 P<0.01. When the mean DASH was compared with the mean  Constant score, No statistical significance was found (p>0.05). however when DASH was compared With Constant and Oxford, Statistical significance at 6 month follow up Was found with p<0.01 (n=30).

Beaton

Prospective Cohort Study

PEDro: 4/10

86 Males 113 Females Age: Mean 53.6

Shoulder, Hand or Wrist pain

Initially 199, Only 172 Completed the study

Inclusions:
Patients with proximal or Distal Disorders of  The upper  extremity

Exclusion: Patients with Tendon Lacerations or  fractures

The DASH  was found to correlate with other measures (r>0.69). The DASH discriminates well between patients who were working and those were not (p<0.0001). Test-retest reliability(ICC=0.96)exceeded guidelines. The DASH was comparable with or better than that of the joint specific measures.

Getahun

Retrospective

PEDro: 6/10

42 Men, Mean Age 58.7.
20 Women Mean Age 61.6.

Patients had Undergone a rotator cuff repair

62 Subjects(75 shoulders)

Inclusion:
Patients who had undergonea rotator cuff repair and were at least 2 years post-repair, averagewas 4 years

Exclusion:
Patients who had tendon transfer repairs, shoulder stabilizations or AC reconstruction unrelated to the rotator cuff

 

 

 

 

Upper extremity questionnaires were highly correlated(0.88<r<0.91)Criterion Validity: excluding IR, the DASH had the 2nd highest correlation (0.33<r<0.52).

Construct validity: ANOVA Analysis Demonstrated the abilityt the DASH to discriminate among levels Of severity of ROM Impairement(p=0.0047).

Henn

Prospective

PEDro: 5/10

72  Males
53 Females Age: 55.15

Patients who underwent a unilateral Primary Rotator cuff repair

125 subjects

Inclusion:
Primary repair of the unilateral symptomatic chronic full thickness rotator cuff tear that had failed to respond to non-operative treatment

Exclusion: Patients if they had an incomplete repair of a massive tear, or had glenohumeral arthritis.

 

Group1: Workers’ Compensation

Group 2: Non-Workers’ Comp.

Preoperative:

G1 DASH= 56.0(18.9) G2DASH=59.8(17.3) p<0.28 postoperative (one year follow-up): G1DASH=72.9(22.7) G2DASH=85.7(17.2 P<0.0007.

Group1 (WC)scored lower on all preoperative and 1 year follow-up when taking DASH, STT, SF-36, and 3 visual analog scales. The DASH testing showed significance in scores postoperative at p<0.0007.

Kennedy

Phase IIexploratory study

PEDro: 5/10

161 Males 194 Females Age: Mean 49.9

Soft tissue shoulder complaints

361 subjects

Inclusion:
Soft tissue  shoulder complaints

Exclusion:
Pts with fractures or dislocations associated with soft tissue pain, received PT for only 1 visit or unable to read or write English

Predictors of higher disability at D/C were: higher initial disability, PT predictions of restrictions at D/C, workers’ comp claim, older age and being female.

Predictors of greater improvement: surgery, higher pain intensity, shorter duration of symptoms, younger age and poorer general physical health.

Baseline: DASH=40.1(19.6) P<0.0001

Discharge (12 wks) DASH 17.9 (16.9)Mean DASH change: 22.2/100

MacDermid

Prospective Cohort Study

97 Males 52 Females Age:56 mean

Rotator cuff tear

149 patients

Inclusion:
Patients who were scheduled to have a rotator cuff repair and were to complete baseline questionnaires

Exclusion: Patients who were unable to complete the self report scales either because of a language barrier or incompetence.

The 4 self reporting questionnaires can discriminate between different responses to rotator cuff repair. The SRM (standardized response means) was found to be WORC=2.02 SST=1.79 DASH=1.63 SF-36= 1.0 for the questionnaires.

Substantial and statistical changes occurred on all 3 scales in the group classified as positive responders. P<0.01

Preoperative: DASH=50.6(1 8.6)

Postoperatively  (6 months):DASH=26.3(1  9.0)

Milano

Prospective Randomized Control  trial

PEDro:7/10

39 Male 32 Female Age: Mean 59.7+-9.7

Full thickness rotator cuff tears

80 Patients 40 in group 1 and 40 in group 2

Inclusion: Patients with a repairable full thickness rotator cuff tear and a type 2 or 3 acromion.

Exclusion:
Partial or irrepairable full thickness rotator cuff  tear, labral pathology amenable for surgical repair, type I acromion, OA of glenohumeral joint, arthritis  of the AC joint, rotator cuff arthropathy, previous surgery in same shoulder and Workers comp:

DASH score for group 1 (with decompression) was 18.2 and 23.1 for patients without decompression. It did not reveal a significant difference between the 2 groups, P=0.604.

Namdari

Retrospective study

PEDro:5/10

24 Males

6 Females Age: Mean 57+-14

Antero-superior rotator cuff tear with an open repair

30 subjects

Inclusion: Traumatic  rotator cuff tear that involved the anterior/superior aspects less than 12 months duration of symptoms and treatment with an open repair

Exclusion: Partial thickness tears, full thickness tears that involved<50% of the insertion, a prior or failed rotator cuff repair, a symptom > 12 months on a traumatic mechanism of injury, or symptoms in the contralateral shoulder

Preoperative: DASH=41.7 P<0.001

Posteroperative (Mean 56 months): DASH=12.2.

 

Skutek

Prospective

PEDro:5/10

16 men and  7 Women Age: Mean55.3+ 10.5

Supraspinatus and infraspinatus tears

23 subjects

No previous surgery on the affected upper extremity

Preoperative DASH=49.58.

Postoperative: DASH=21.62.

There was a significant correlation between the Constant-Murley Shoulder score and the DASH r=-0.758 P<0.01.

Tashjian

Prospective and Retrospective

PEDro:4/10

65 Shoulders men 53 Shoulders women Age: Mean 59

Subjects who underwent rotator cuff repair

112 subjects (118 shoulders)

 

Inclusion: Patients who did not improve with nonoperative treatment with a physical therapy program, or a corticosteroid injection

Exclusion: Patients with glenohumeral arthritis, adhesive capsulitis and h/o a workers’ compensation claim.

 

Preoperative DASH=41.79

Postoperatively ( Mean 54 months): DASH=15.42, P<0.01.

There was statistically significant correlations between postoperative patient satisfaction and the absolute scores of the DASH, p<0.104. Correlations between the retrospective function and prospective DASH were lower than the correlations between the retrospective outcome and postoperative satisfaction.

The articles included in our review did not report psychometrics, such as reliability and validity, for the DASH outcome measure. The psychometrics for the DASH were completed in previous studies.

Author

Sample Size

Cronbach α Coefficient

SRM

Change DASH

Test-retest reliability

Significance

Gummesson

N= 109

>0.9

1.2

15 (SD 13)

 

 

Kitis

N= 240

0.91

 

 

ICC 0.92

P <0.05

Raven

N= 120

0.97

 

 

ICC 0.97

 

DISCUSSION

It was the goal of this systematic review to present a summary of available research by assessing the quality of the investigations as they pertained to our predetermined criteria and scoring methods. In the age of evidence based clinical practice, it is our professional responsibility to provide our clients with the best available therapeutic interventions and outcome measurements.

The DASH questionnaire consists of thirty items and is a regional outcome measure suitable for patients with musculoskeletal conditions of the upper limb.  Six domains are assessed: daily activities, symptoms, social function, work function, sleep and confidence.  The scores of each section are used to calculate a total ranging from 0 (no disability) to 100 (severe disability).7  The DASH questionnaire is very useful in clinical practice.  It is self-administered allowing for the inclusion of a personal factor in the DASH content reinforcing the extent in measuring disability and health.  Another key point is that it only takes about 10 minutes to complete and is practical to use.8

We performed a systematic review of the literature to determine if the DASH is an accurate measure of outcomes post rotator cuff repair.  Based on the reported studies, we deducted that the DASH is a valid tool and it can detect small and large changes of disability over time after surgery.11

Limitations

The International Classification of Functioning, Disability and Health (ICF) is a classification framework of health and health related domains.  These domains include body function and structure, activities (what a person with a health condition can do taking into consideration environmental factors), and participation (what a person with a health condition can actually perform).  This framework identifies outcome measures relevant to our clients.  The domain of activities as it pertains to social and cultural environmental factors, in addition to a client’s social support, is not recognized in the DASH scoring content.  This is important to discuss because of how important these factors affect a patient’s total rehabilitation outcome. 8  Other limitations can include the incorrect scoring of the DASH and possible incomplete responses by the patient (need 27/30).  Future research shoulder be conducted which includes these domains, possible as an optional component to the DASH such as the sports/music component.

CONCLUSION

In summary, there is evidence that supports the DASH questionnaire as a valid and accurate instrument in assessing outcomes post rotator cuff repair.  The available research supports the use of the DASH in clinical practice.

REFERENCES

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  2. Alotaibi N. The cross-cultural adaptation of the disability of arm, shoulder and hand (DASH); a systematic review. Ocup Ther Int. 3008; 15(3):178-190.

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  4. Beaton, DE, Katz JN, Fossel, AH, Wright JG, Tarsuk V, Bombardier C. Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder, and Hand outcome measure in different regions of the upper extremity. J Hand Ther. 2001; 14:128-46.

  5. Davidson J. A Comparison of the Upper Limb Amputees and Patients with Upper Limb Injuries Using the Disabilities of the Arm, Shoulder and Hand (Dash). Disabilities and Rehabilitation. 2004; 26:917-923.

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  8. Drummond AS, Sampaio RF et al. Linking the Disabilities of the Arm, Shoulder and Hand to the International Classification of Functioning, Disability and Health. Journal of Hand Therapy. 2007; 20:336-344.

  9. Gartsman G, Hasan S. What’s new in shoulder and elbow surgery? Journal of Bone & Joint Surgery – American Volume. 88-A(1):230-243, January 2006.

  10. Getahun, TY, MacDonald JC, Patterson SD. Concurrent Validity of Patient Rating Scales in Assessment of Outcome after Rotator Cuff Repair. J of Musculoskeletal Res. 2000; 4:2:119-127.

  11. Gummesson, C, Atroshi I, Ekdahl C. The Disabilities of the Arm, Shoulder and Hand (Dash) Outcome Questionnaire: Longitudinal Construct Validity and Measuring Self Rated Health Change After Surgery. BMC Muscoloskeletal Disorders. 2003; 4:11.

  12. Henn Rf 3rd. Kang L. Tashjian RZ, Green A. Patients with worker’s compensation claims have worse outcomes after rotator cuff repair. Journal of Bone & Joint Surgery – American Volume. 2008; 90(10):2105-13.

  13. Hudak, Amadio PG, Bombardier C. The Upper Extremity Collaborative Group. Development of an Upper Extremity Measure: the DASH (Disabilities of the Arm, Shoulder and Hand). Am J Ind Med. 1996; 29:618-31.

  14. Kennedy CA, Manno M, et al. Prognosis in Soft Tissue Disorders of the Shoulder: Predicting Both Change in Disability and Level of Disability after Treatment. Physical Therapy. 2006; 86:1013-1032.

  15. Kirkley A, Griffin S, Dainty K. Scoring Systems for the functional assessment of the shoulder. Arthroscopy. 2003; 19(10):1119-20.

  16. Kitis A, Celik E, Aslan UB, Zencir M. DASH questionnaire for the analysis of musculoskeletal symptoms in industry workers: a validity and reliability study. Appl Ergon. 2009 Mar; 40(2):251-5.

  17. MacDermid JC, Drosdiwweck D, Faber K. Responsiveness of self report scales in patients recovering from rotator cuff surgery. Journal of Shoulder and Elbow Surgery. 2006; 15(4):407-14.

  18. McLeod TCV, Snyder AR, Parsons JT, Bay, RC, Michener LA, Sauers RL. Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, part II : clinical outcomes assessment. J Athletic Training. 2008; 43(4):437-445

  19. Milano, G, Grasso A, Salvatore M, Zarelli D, Deriu L, Fabbriciani C. Arthroscopic rotator cuff repair with and without subacromial decompression: a prospective randomized study. Arthroscopy. 2007 Jan; 23(1):81-8.

  20. Namdari, Surena MD1; Hen, R Frank III Md 2; Green, Andrew MD 3 Traumatic Anterosuperior Rotator Cuff Tears: The Outcome of Open Surgical Repair. Journal of Bone & Joint Surgery – American Volume. 2008 September; 90(9):1906-1913.

  21. Oh JH, Kim SA, Ji HM, Jo Kh, Bin SW, Gong Hs. Prognastic factors affecting outcome of rotator cuff repair and correlation with functional outcome. Arthroscopy. 2009; 25(1):30-39.

  22. Raven EE, Haverkamp D, Sierevelt IN, Van Montfoort DO, Poll RG, Blackevoort L, Tak PP. Construct validity and reliability of the disability of arm, shoulder and hand questionnaire for the upper extremity complaints in rheumatoid arthritis. J Rheumatol. 2008 Dec; 35(12):2334-8.

  23. Skutek M, Fremerey RW, Zeichen J, Bosch U. Outcome Analysis Following Open Rotator Cuff Repair. Early Effectiveness Validating Using Four Different Shoulder Assessment Scales. Archive Orthopedic Trauma Surgery. 2000; 120:432-436.

  24. Soohoo NF, McDonald AP Seller JG III, McGillivary Gr. Evaluation of construct validity of the DASH questionnaire by correlation to the SF-36. J Hand Surg (AM). 2002; 27:537-41.

  25. Tashjian A, Bradley M, Tocci S, Henn R, Rey J, Green A. A Comparison of Prospective and Retrospective Assessment of Functional Outcome after Rotator Cuff Repair. Journal of Elbow and Shoulder Surgery. 2008; 17:853-859.

  26. Tashjian RX, Henn R, Kang L, Green A. The effect of comorbidity on self-assesses function in patients with chronic rotator cuff tear. Journal of Bone & Joint Surgery – American Volume. 2004 February; 86-A(2):355-362.

  27. Wade DT. Outcome measures for clinical rehabilitation trials: impairment, function, quality of life or value? Am J Phys Med Rehabil. 2003; 82(10):S26-S31.

  28. Portney LG, Watkin MP. Foundations of clinical research: applications to practice 3rd edition. Pearson Prentice Hall. 2009; 360-381.
 


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