Arthritis & Rheumatism (Arthritis Care & Research)

Vol. 61, No. 5, May 15, 2009, pp 623– 632

DOI 10.1002/art.24396
© 2009, American College of Rheumatology
ORIGINAL ARTICLE

Measuring Shoulder Function: A Systematic

Review of Four Questionnaires
JEAN-SÉBASTIEN ROY,1 JOY C. MACDERMID,2 AND LINDA J. WOODHOUSE3

Objective. To conduct a systematic review of the quality and content of the psychometric evidence relating to 4 shoulder
disability scales: the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Shoulder Pain and Disability
Index (SPADI), the American Shoulder and Elbow Surgeons (ASES) score, and the Simple Shoulder Test (SST).
Methods. We conducted a structured search using 3 databases (Medline, CINAHL, EMBase). In total, 71 published
primary studies were analyzed. A pair of raters conducted data extraction and critical appraisal using structured tools.
A descriptive synthesis was performed.
Results. Quality ratings of 55% of the studies reviewed reached a level of >75%. Most studies suggest that all 4
questionnaires have excellent reliability (intraclass correlation coefficient >0.90). The 4 questionnaires are strongly
correlated (r >0.70) with each other and with a number of similar indices, and the questionnaires were able to
differentiate between different populations and disability levels. The minimal detectable change (MDC) is ⬃9.4 for the
ASES, 10.5 for the DASH, and 18 for the SPADI; the minimal clinically important difference (MCID) is ⬃6.4 for the ASES
and 10.2 for the DASH, and ranges between 8 and 13 for the SPADI. MDC and MCID have not been defined for the SST.
Conclusion. The psychometric properties of the ASES, DASH, and SPADI have been shown to be acceptable for clinical
use. Conversely, some properties of the SST still need be evaluated, particularly the absolute errors of measurement.
Overall, validation studies have focused on less clinically relevant properties (construct validity or group reliability) than
estimates of MDC and MCID.

INTRODUCTION
Shoulder pain is a common and disabling condition. Over
the past decade, there has been a proliferation of self-
reported shoulder disability questionnaires. In a system-
atic review, Bot et al identified all available shoulder dis-
ability questionnaires up to July 2002 designed to measure
physical functioning, and evaluated evidence for the psy-
chometric qualities of these instruments (1). Sixteen ques-
tionnaires were identified and critically appraised by 2
raters. They observed that the Disabilities of the Arm,
Shoulder, and Hand (DASH) questionnaire, the Shoulder
Pain and Disability Index (SPADI), the American Shoulder
1
Jean-Sébastien Roy, PT, PhD: McMaster University,
Hamilton, Ontario, Canada; 2Joy C. MacDermid, PT, PhD:
McMaster University, Hamilton, Ontario, Canada, and St.
Joseph’s Health Center, London, Ontario, Canada; 3Linda J.
Woodhouse, PT, PhD: McMaster University and Hamilton
Health Sciences, Hamilton, Ontario, Canada, and Holland
Orthopaedic & Arthritic Hospital of Sunnybrook Health Sci-
ences Centre, Toronto, Ontario, Canada.
Address correspondence to Jean-Sébastien Roy, PT, PhD,
School of Rehabilitation Science, McMaster University, Ham-
ilton, Ontario, Canada, L8S 1C7. E-mail: jean-sebastien.roy.
1@ulaval.ca.
Submitted for publication September 25, 2008; accepted
in revised form January 16, 2009.
and Elbow Surgeons (ASES) score, and the Simple Shoul-
der Test (SST) were studied the most. Overall, the DASH
received the best ratings for its psychometric properties.
This study concluded that published validation studies
had limitations in terms of the scope, particularly in the
study design, sample sizes, and evidence for dimension-
ality. Additional publications available since this 2002
study suggest that there may be evidence to fill these gaps.
When conducting a systematic review, it is important to
have a sufficient number of studies to make meaningful
conclusions. When there is only sparse evidence available,
it is impossible to synthesize data or make any specific
recommendations about these tools. An inventory of the
self-reported shoulder scales (see Supplemental Appendix
A, available in the online version of this article at http://
www3.interscience.wiley.com/journal/77005015/home)
shows that the ASES, DASH, SPADI, and SST are the only
questionnaires that have more than 10 studies evaluating
their psychometric properties. Therefore, the quantity of
evidence available to perform a systematic review was
only sufficient for these instruments. This agrees with
conclusions from Bot and colleagues (1), who also deter-
mined that these scales were the most frequently studied.
Four other systematic reviews of shoulder disability
questionnaires have been published (2–5). Fayad et al
reviewed 38 shoulder questionnaires (3) and concluded

623
624 Roy et al

that there is no gold standard for assessing shoulder func-
tion outcome. The 3 other published systematic reviews
were specific to a population (shoulder/upper extremity
disorders in athletes [2] or following trauma [4]) or to a
psychometric property (cross-cultural adaptation of the
DASH [5]). None of the 4 systematic reviews used multiple
raters for critical appraisal or performed a quantitative
synthesis of the studies reviewed.
The purpose of this study was to conduct a systematic
review of the quality and content of the psychometric
evidence relating to 4 commonly used self-reported shoul-
der disability scales: the ASES, DASH, SPADI, and SST
questionnaires.
MATERIALS AND METHODS
Description of the questionnaires. Three shoulder-spe-
cific scales (ASES, SPADI, and SST) and 1 scale that eval-
uates the entire upper extremity (DASH) were reviewed in
this systematic review.
Disabilities of the Arm, Shoulder, and Hand question-
naire. The DASH was developed to measure physical dis-
ability and symptoms of the upper extremities in people
with upper extremity disorders (hand, wrist, elbow, and
shoulder) (6). It is a 30-item scale that addresses difficulty
in performing various physical activities that require up-
per extremity function (physical function, 21 items);
symptoms of pain, activity-related pain, tingling, weak-
ness, and stiffness (pain symptoms, 5 items); or impact of
disability and symptoms on social activities, work, sleep,
and psychological well-being (emotional and social func-
tion, 4 items). The score ranges from 0 to 100, where 0 ⫽
no disability and 100 ⫽ most severe disability.
Shoulder Pain and Disability Index. The SPADI is a
self-report questionnaire developed to measure the pain
and disability associated with shoulder pathology in peo-
ple with shoulder pain of musculoskeletal, neurogenic, or
undetermined origin (7). It consists of 13 items in 2 do-
mains: pain (pain symptoms, 5 items) and disability (phys-
ical function, 8 items). The items of both domains were
scored on a visual analog scale ranging from 0 to 100,
where 0 ⫽ no pain/no difficulty and 10 ⫽ worst pain
imaginable/so difficult required help. Each domain score
was equally weighted, then added for a total percentage
score ranging from 0 to 100, where 0 ⫽ best and 100 ⫽
worst.
American Shoulder and Elbow Surgeons score. The
ASES was developed to measure functional limitations
and shoulder pain in people with musculoskeletal pathol-
ogies (8). Pain score was calculated from a single pain
question on a visual analog scale (pain symptoms) and a
function score from the sum of 10 questions addressing
function using a 4-point ordinal scale (physical function).
Pain and function are weighted equally and the total score
ranges from 0 to 100 points, where 0 ⫽ worst and 100 ⫽
best.
Simple Shoulder Test. The SST measures functional
limitations of the affected shoulder in people with shoul-
der dysfunction (9), and consists of 12 questions with
dichotomous (1 ⫽ yes or 0 ⫽ no) response options. For
each question, the patients indicated that they were able or
were not able to do the activity (physical function). The

Table 1. Definitions of the psychometric properties*

Psychometric property Definition

Floor and ceiling effects The extent to which scores cluster near the less (floor)/more (ceiling)
desirable health state extreme on the scale.
Responsiveness The ability of a measure to assess clinically important change over time.
Effect size Mean change in score divided by the SD of the pretreatment score.
SRM Mean change in score divided by the SD of the change in score.
MCID The smallest change that represents an important difference for the patient
(same unit as the original measurement).
Test–retest reliability The extent to which multiple applications of a test provide consistent results.
ICC A measure of relative reliability; variance owing to the objects of
measurement divided by the total variance (coefficient: ⫺1 to 1).
SEM A measure of absolute reliability; represents the SD of measurement errors
(same unit as the original measurement).
MDC An estimate of the smallest change that can be detected by a patient (same
unit as the original measurement), based on the SEM.
Validity The extent to which a measure assesses what it is intended to measure.
Construct The extent to which scores on the questionnaire relate to other measures in a
manner that is consistent with theoretically derived hypotheses concerning
the domains that are measured.
Content The extent to which the domain of interest is comprehensively sampled by
the items in the questionnaire.
Factorial Interrelationships among a set of variables; the underlying dimensions or
constructs that explain the relationships among observed variables.
Internal consistency The extent to which items in a scale are homogeneous.

* SRM ⫽ standardized response mean; MCID ⫽ minimal clinically important difference; ICC ⫽ intraclass correlation coefficient;
SEM ⫽ standard error of the measure; MDC ⫽ minimal detectable change.
Systematic Review of Shoulder Questionnaires 625

scores range from 0 to 100, where 0 ⫽ worst and 100 ⫽

best, and are reported as the percentage of items that a
person reports being able to do.

Literature search and study identification. A database

search using Medline, CINAHL, and EMBase was per-
formed. The following keywords were used to search da-
tabases for eligible studies: (Disabilities of the Arm, Shoul-
der and Hand or Shoulder Pain and Disability Index or
American Shoulder and Elbow Surgeons score or Simple
Shoulder Test) and (reliability or validity or responsive-
ness or minimal detectable change or minimal clinically
important difference or Rasch or factor analysis or trans-
lation or validation). Hand searches of retrieved study
reference lists were also conducted. Articles published
between 1966 and August 2008 were included.
The abstracts of each article were independently re-
viewed by 2 of the authors, and the article was accepted for
a full review if it met the following inclusion criteria: 1)
reported on at least 1 psychometric property, 2) written in
French or English, 3) evaluated the DASH, SPADI, ASES,
or SST, and 4) included subjects with shoulder disorders.
A pair of raters independently reviewed each article that
met the inclusion criteria. A data extraction form adapted
from Eechaute et al (10) and a quality appraisal tool (11)
were used to collect and synthesize data. The items from
the quality appraisal tool are listed in Supplemental Ap-
pendix B (available in the online version of this article at
http://www3.interscience.wiley.com/journal/77005015/
home). All of the authors first met for a calibration review,
where they independently reviewed 2 articles. They dis- Figure 1. Flow chart of the systematic review evidence.
cussed each item to clarify the meaning and interpretation
of critical appraisal items. Then the pair of raters indepen-
dently evaluated an assigned subset of articles using the
RESULTS
data extraction form and quality appraisal tools. A total of 89 articles were reviewed (Figure 1). Seventy-
After the independent evaluation, the pair of raters met one articles met all inclusion criteria and were included
to discuss the article. Each specific item on the extraction for full review (see Supplemental Appendix C, available
forms and quality appraisal tool was openly discussed to in the online version of this article at http://www3.
reach consensus. This process identified whether disagree- interscience.wiley.com/journal/77005015/home). Quality
ments were related to facts or adherence to the defined of the individual studies ranged from 25% to 96%, with
standard. When no consensus was achieved, raters consid- 55% of studies reaching or exceeding a score of 75% on
ered the default option to be the lower score. If any rater the quality rating (see Supplemental Appendix B, avail-
was uncomfortable with this resolution, a third rater re- able in the online version of this article at http://
viewed and scored the article. Each total score was con- www3.interscience.wiley.com/journal/77005015/home).
verted into a percentage. Weighted kappa was used to The overall interrater reliability of the critical appraisal
calculate preconsensus interrater agreement on individual tool was excellent (ICC 0.91, 95% confidence interval
items, and an intraclass correlation coefficient (ICC) was [95% CI] 0.86 – 0.94), with agreement on individual items
used to evaluate interrater reliability of the total score. ranging from fair to excellent (␬ ⫽ 0.43– 0.92).
Studies were rank ordered for quality, and this ranking
was considered in conclusions and recommendations. Readability/language and cultural translation. All 4
However, there was no formal mechanism to weight con- questionnaires reviewed were comprehensive and in-
clusions based on the quality of the associated source cluded items that were easy to understand. The SPADI has
document. Overall relative and absolute reliability and been translated into German and Turkish (13,14) and the
responsiveness were determined by calculating a weighted ASES has been translated into German (15), whereas the
average over all studies (weighted by sample size). Defini- DASH has been translated into 16 languages. The SST is
tions of the psychometric properties extracted from the only available in English. Overall, the English version and
studies for this systematic review are shown in Table 1 all translated versions have been deemed to be acceptable
(1,12). for validity content.
626
Table 2. Comparison between validity and reliability in studies evaluating more than one questionnaire*
Population
Time to complete, minutes
Rotator cuff disorders (16)
Tendinitis/impingement (24)
Known group validity (ANOVA, ability to discriminate) (33)
Levels of ROM impairment
Worker’s compensation status
Reliability (ICC, SEM, or MDC)
Shoulder arthroplasty (58), ICC
Shoulder disorders (24), ICC
Shoulder pain/dysfunction (50), ICC
Postsurgical
Nonsurgical
Tendinosis/impingement (52), ICC
Tendinosis/impingement (52), SEM
Tendinosis/impingement (52), MDC (90% CI)
* ASES ⫽ American Shoulder and Elbow Surgeons score; DASH ⫽ Disabilities of the Arm, Shoulder, and Hand questionnaire;
SPADI ⫽ Shoulder Pain and Disability Index; SST ⫽ Simple Shoulder Test; ANOVA ⫽ analysis of variance; ROM ⫽ range of
motion; ICC ⫽ intraclass correlation coefficient (relative reliability); SEM ⫽ standard error of the measure (absolute reliability);
MDC ⫽ minimal detectable change; 90% CI ⫽ 90% confidence interal.
Administration burden. The results in terms of re-
sponder burden for the DASH are quite variable (16 –23),
with mean times ranging from 4 (16) to 13 minutes (23) to
complete and 2 to 6 minutes to analyze (19). Two studies
have addressed the time taken to complete the SPADI and
the ASES; one reported a mean time of 2 minutes (16),
whereas the other reported a time ranging from 3 to 5
minutes (24) (Table 2). Finally, a time of ⬍3 minutes to
complete the STT was reported (24) (Table 2).
Floor and ceiling effects. Floor and ceiling effects of the
4 questionnaires have been addressed. Godfrey and col-
leagues reported that 1.6% of patients demonstrated a floor
effect and 7.1% demonstrated a ceiling effect when using
the SST (25). Angst et al observed a ceiling effect of 8% on
the ASES questionnaire (16), whereas Goldhahn et al dem-
onstrated that some items of the ASES showed high ceiling
effects, such as item 04 (92%; “Do you take narcotic pain
medication?”) and item 07 (86%; “Does your shoulder feel
unstable?”) (15). Although no floor or ceiling effects (26) or
very low ceiling effects (7%) (13,16) have been observed
for the SPADI, some items showed relatively high floor
effects (e.g., item 10: “Putting on your pants”) of up to 61%
(13,16). As for the DASH, most of the studies have not
detected any (16,18,23,27–30) or have found very low floor
effects (0.8 – 4.4%) (19,31) or ceiling effects (0.5%) (32).
Validity. Construct convergent validity has been estab-
lished between the 4 questionnaires reviewed and a
variety of other questionnaires or variables. Correlations
between the SST, ASES, SPADI, and DASH were high
(r ⱖ0.70) (25,33,34), which is consistent with the similar-
ity in their constructs. Strong correlations (r ⱖ0.70) were
also observed between the 4 studied questionnaires and
other scales such as the Constant-Murley scale (16,35,36),
the Shoulder Severity Index (34), the Western Ontario
Rotator Cuff Index (33,37,38), the Oxford Shoulder Ques-
Roy et al
ASES DASH SPADI SST
2 4 2
3–5 3–5 ⬍3
P ⫽ 0.005 P ⫽ 0.003
P ⬍ 0.001 P ⬍ 0.001
0.93 0.96 0.94
0.96 0.91 0.99
0.91 0.91
0.84 0.84
0.91 0.86
5.22 7.75
12.2 18.1
tionnaire (39), the Shoulder Rating Questionnaire (40), and
the University of Pennsylvania Shoulder Scale (41,42).
Weaker correlations (r ⫽ 0.30 – 0.70) were observed with
less similar indices such as the Short Form 36 or clinical
variables such as patient satisfaction (43), shoulder range
of motion (7,34,36), shoulder strength (36,44), or joint
irritability (45). The content of the 4 questionnaires has
been shown to be valid in evaluating pain and disability
for different shoulder conditions. Known group validity
has shown that the ASES, DASH, SPADI, and SST can
differentiate between different populations and disability
levels (Table 3).
The dimensional structures of the 4 questionnaires have
been evaluated using factor analysis. Although the SST
claims to measure a single construct, it has been suggested
that the SST is a 2-dimensional scale (46,47). According to
Roddey and colleagues, the first dimension measures what
patients can do with their shoulder and the second dimen-
sion measures the patient’s comfort with their shoulder at
rest (46). As for the ASES, factor analysis suggests that it
evaluates 2 dimensions (pain and function) (47). Most of
the studies that have evaluated the dimensional structure
of the SPADI have suggested that it has 2 dimensions
(7,45,47,48), with a majority of disability items loading on
the first factor and a majority of pain items loading on the
second. Conversely, Bumin et al (14) extracted 3 domains
in the Turkish version of the SPADI, whereas Roddey et al
(46) extracted only one factor. This suggests that the scale
may have 1–3 dimensions, depending on the groups eval-
uated. Finally, one major factor has been suggested for the
DASH (disabilities and symptoms) (21,28 –30,49). Internal
consistency has been evaluated for the 4 questionnaires.
Overall, Cronbach’s alpha ranged from 0.85 to 0.97.
Reliability. Studies have demonstrated good test–retest
reliability for the 4 questionnaires. The relative reliability
of the SST has been shown to be excellent (weighted
Systematic Review of Shoulder Questionnaires 627

Table 3. Known group validity*

ASES
Detected differences between:
Gotten much better ⫽ 80.4; gotten slightly better ⫽ 67.0 (42)
Minimally functionally limited ⫽ 66.1; moderately functionally limited ⫽ 45.0;
maximally functionally limited ⫽ 40.7 (rated by a therapist) (42)
DASH
Detected differences between:
Currently working ⫽ 26.8; not able to work ⫽ 50.7 (32)
Able to do all they want ⫽ 23.6; not able to do so ⫽ 47.1 (32)
Patients’ shoulder external rotation ROM: ⬎45° ⫽ 82; ⬍45° ⫽ 67 (33)
Worker’s compensation status: yes ⫽ 83; no ⫽ 58 (33)
Disease state: soft ⫽ 39.0; heavy ⫽ 56.9 (49)
Health state: good ⫽ 25.8; fair ⫽ 52.8; poor ⫽ 77.1 (49)
SPADI
Patients who had diagnosed shoulder problems and those on pain medication
reported higher pain and disability scores (45)
SST
Detected differences between:
Patients age ⱖ60 years ⫽ 5.78; patients age ⬍60 years ⫽ 7.09 (25)
Patients with shoulder instability ⫽ 7.50; with rotator cuff injury ⫽ 6.29 (25)
Worker’s compensation ⫽ 7.83; non–worker’s compensation ⫽ 10.12 (25)
Shoulder external rotation ROM: ⬎45° ⫽ 79; ⬍45° ⫽ 61 (33)
Worker’s compensation status: yes ⫽ 55; no ⫽ 79 (33)

* ASES ⫽ American Shoulder and Elbow Surgeons score; DASH ⫽ Disabilities of the Arm, Shoulder, and
Hand questionnaire; ROM ⫽ range of motion; SPADI ⫽ Shoulder Pain and Disability Index; SST ⫽ Simple
Shoulder Test.

average 0.98) (24,25) (Table 4). The relative reliability of
the STT has been shown to be superior to the ASES and
the SPADI for patients with different shoulder disorders
(24) (Table 2). Absolute reliability and minimal detectable
change (MDC) were not reported for the SST in the re-
viewed studies. The relative reliability of the ASES is also
excellent, with an ICC ⬎0.84 (ICC 0.84 – 0.96; weighted
average 0.91) (15,24,42,50,51) (Table 4). Only Michener
and colleagues have addressed the absolute reliability and
MDC of the ASES (42). They reported the standard error of
the measure (SEM) of 6.7 points and MDC of 9.4 points,
with 90% confidence intervals (90% CIs) for patients with
various shoulder pathologies (42) (Table 4).
All but one study reported an excellent reliability for the
SPADI, with ICCs varying from 0.85 to 0.95 (weighted
average 0.89) (13,24,26,44,52) (Table 4). Roach et al ob-
served a reliability of only 0.66 for the SPADI in a study of
23 patients (7), whereas more recent large high-quality
studies have indicated higher reliability (ICC ⱖ0.85)
(26,52). One study (13) reported an SEM of 6.2 points and
an MDC of 18 points with a 95% CI for patients who had
undergone primary shoulder arthroplasty, whereas for a
more general population of patients with upper extremity
musculoskeletal problems, an SEM of 7.75 points and an
MDC of 18.1 points with 90% CIs were reported (52)
(Table 4).
Finally, relative reliability of the DASH has been shown
to be excellent, with ICCs varying from 0.82 to 0.98
(weighted average 0.90) (18 –20,22,28 –30,32,52–57) (Table
4), except for the Chinese version of the DASH, where the
reliability was good (ICC 0.77) (21). The relative reliability
of the DASH has been shown to be superior to the SPADI
and the ASES for evaluation of patients following shoulder
arthroplasty (58) (Table 2). The SEM of the DASH has been
shown to vary from 2.84 to 5.22 (weighted average 4.5),
and the MDC (90% CI) from 6.6 to 12.2 points (weighted
average 10.5) (19,32,52) (Table 4). Relative and absolute
reliability and the MDC have been reported to be better for
the DASH than for the SPADI for patients with shoulder
tendinosis and impingement (52) (Table 2).
Responsiveness. All 4 questionnaires have been shown
to have good responsiveness, with a reported effect size
(ES) or standardized response mean (SRM) of ⬎0.80 and a
weighted average of ⬎1.10 for a cohort of patients that
improved following either surgery or rehabilitation (Table
4). However, responsiveness varies widely depending on
the population and intervention evaluated. Responsive-
ness for the ASES (ES ⫽ 2.13, SRM ⫽ 1.81) has been
shown to be superior to that of the SPADI (ES ⫽ 2.10,
SRM ⫽ 1.72) and the DASH (ES ⫽ 1.19, SRM ⫽ 1.22)
following shoulder arthroplasty (58), whereas responsive-
ness of the SPADI (SRM ⫽ 1.23) was superior to that of the
ASES (SRM ⫽ 0.93) and the SST (SRM ⫽ 0.87) (24), and
the SST (SRM ⫽ 1.79) was superior to the DASH (SRM ⫽
1.63) (59) in patients following rotator cuff surgery (Table
5). Finally, the responsiveness of the SPADI (ES ⫽ 1.21,
SRM ⫽ 1.08) has been shown to be superior to that of the
DASH (ES ⫽ 1.06, SRM ⫽ 1.08) (52) following treatment
for shoulder tendinosis and impingement (Table 5). Re-
sponsiveness is low (ES or SRM ⫽ 0.54 – 0.88) for the 4
questionnaires when measured in a cohort of subjects with
shoulder instability (25,51,60).
Few of the reviewed studies calculated the minimal
clinically important difference (MCID), and there were no
628 Roy et al

Table 4. Average reliability and responsiveness across studies weighted by sample size*

ASES DASH SPADI SST

ICC
Range 0.84–0.96 0.77–0.98 0.66–0.95 0.97–0.99
No. subjects (no. studies) 334 (5) 957 (15) 339 (6) 71 (2)
Average 0.91 0.90 0.89 0.98
SEM
Range 6.7 2.8–5.2 6.2–7.8 N/E
No. subjects (no. studies) 63 (1) 172 (3) 196 (2)
Average 6.7 4.5 6.8
MDC 90% CI
Range 9.4 6.6–12.2 18.1 N/E
No. subjects (no. studies) 63 (1) 172 (3) 78 (1)
Average 9.4 10.5 18.1
MDC 95% CI
Range N/E 7.9–12.8 18.0 N/E
No. subjects (no. studies) 94 (2) 118 (1)
Average 10.8 18.0
MCID
Range 6.4 10.2 8 and 13.2 N/E
No. subjects (no. studies) 59 (1) 155 (1) 90 and 44 (2)
Average N/A N/A
ES, all studies
Range 0.9–3.5 0.4–1.4 1.2–2.1 0.8
No. subjects (no. studies) 1,300 (4) 824 (8) 383 (3) 596 (1)
Average 1.3 1.1 1.6 0.8
ES, improved cohort
Range 1.4 1.1 1.2–1.5 N/E
No. subjects (no. studies) 55 (1) 355 (2) 245 (2)
Average 1.4 1.1 1.3
SRM, all studies
Range 0.5–1.6 0.5–2.2 1.1–1.7 0.8–1.8
No. subjects (no. studies) 1,465 (8) 946 (9) 573 (6) 715 (3)
Average 1.1 1.1 1.3 0.9
SRM, improved cohort
Range 0.9–1.5 1.1–1.6 1.1–1.4 0.9–1.8
No. subjects (no. studies) 88 (2) 441 (3) 435 (5) 119 (2)
Average 1.3 1.4 1.2 1.5

* ASES ⫽ American Shoulder and Elbow Surgeons score; DASH ⫽ Disabilities of the Arm, Shoulder, and Hand questionnaire;
SPADI ⫽ Shoulder Pain and Disability Index; SST ⫽ Simple Shoulder Test; ICC ⫽ intraclass correlation coefficient; SEM ⫽
standard error of the measure; N/E ⫽ not evaluated; MDC ⫽ minimal detectable change; 90% CI ⫽ 90% confidence interval; 95%
CI ⫽ 95% confidence interval; MCID ⫽ minimal clinically important difference; N/A ⫽ not applicable; ES ⫽ effect size; SRM ⫽
standardized response mean.

reports of this measure for the SST. The MCID of the ASES
was reported to be 6.4 points (42). MCIDs of 10.2 points for
the DASH and 13.1 points for the SPADI have been shown
to be associated with a change of ⫹1 on the Global Dis-
ability Rating score (52) (Table 4). For the SPADI, an MCID
of 8 points has been shown to differentiate between pa-
tients who improve and those who do not (40).
DISCUSSION
In this study, 71 studies addressing the psychometric
properties of 4 commonly used shoulder disability ques-
tionnaires were evaluated. Data extraction and critical ap-
praisal were performed in order to synthesize current ev-
idence. Overall, the DASH is the most extensively studied
questionnaire, mainly because of the multiple cultural ad-
aptation studies conducted. The ASES and the SPADI are
also widely evaluated. Therefore, the psychometric prop-
erties of the ASES, DASH, and SPADI have been shown to
be acceptable for research and clinical use. Conversely, the
SST is the least studied questionnaire, and some of its
psychometric properties still need to be evaluated.
The reviewed questionnaires have been shown to have
excellent reliability. Of the 4 questionnaires, the SST has
demonstrated the highest level of relative reliability. How-
ever, only 2 small (n ⫽ 41 and 30) test–retest studies were
identified (24,25), suggesting that these estimates may be
less stable than those obtained for the other scales. Large
high-quality studies are needed to confirm these findings. In
their systematic review, Bot et al suggested that the SPADI
may not be applicable for individual patients because of its
low level of reliability (1). Since then, high-quality studies
have shown that relative reliability of the SPADI is excellent
(ICC ⬎0.85), addressing the concern raised by Bot et al. The
weighted average suggests that the relative reliabilities of
the ASES, SPADI, and DASH are in the same range. How-
Systematic Review of Shoulder Questionnaires
Table 5. Comparison between responsiveness in studies evaluating more than
one questionnaire*
Population
Arthroplasty (58), ES/SRM
Total score
Pain subscale
Function subscale
Arthroplasty, rotator cuff surgery (24), SRM
Shoulder disorders (32), SRM
Problem better
Function better
Shoulder instability (60), SRM
Rotator cuff repair (59), SRM
Improved
Deteriorated
Tendinosis/impingement (52), ES/SRM
Shoulder pain, tendinosis, and impingement
(ROC, change of 1 on the Global
Disability Rating) (52), MCID
* ASES ⫽ American Shoulder and Elbow Surgeons score; DASH ⫽ Disabilities of the Arm, Shoulder, and Hand
questionnaire; SPADI ⫽ Shoulder Pain and Disability Index; SST ⫽ Simple Shoulder Test; ES ⫽ effect size;
SRM ⫽ standardized response mean; ROC ⫽ receiver operating characteristic curve; MCID ⫽ minimal clinically
important difference.
ever, absolute measurement errors (SEM and MDC) are
higher for the SPADI, which should be considered when
using a questionnaire for test–retest purposes.
The observed ES and SRMs suggest that the 4 question-
naires are responsive enough to be used with different
shoulder conditions, except possibly shoulder instability.
The reviewed studies demonstrate that these question-
naires are not highly sensitive for a population with shoul-
der instability (25,51,60). Of the 4 questionnaires, only the
ASES has specific questions related to instability. How-
ever, the responsiveness of the ASES for this population is
lower than that of the DASH, although the DASH contains
no specific questions on shoulder instability and is not a
shoulder-specific questionnaire (60). Therefore, condition-
specific questionnaires designed for shoulder instability
may be needed for this subgroup. For example, the West-
ern Ontario Shoulder Instability Index has been shown to
have an ES of 0.93 for this population (60). The SPADI and
the ASES are the most responsive questionnaires in pa-
tients following shoulder arthroplasty (58) and are recom-
mended for use with this population. Conversely, the 4
questionnaires seem to be equivalent for other shoulder
conditions such as shoulder pain, tendinosis, and im-
pingement. Since responsiveness is related to the potential
for clinical improvement, scores can only be compared
across similar clinical populations.
Floor and ceiling effects are normally considered a prob-
lem when more than 15% of patients achieve the highest
or lowest possible score (61). Therefore, none of the ques-
tionnaires was labeled as having a floor or ceiling effect.
The administrative burden has been shown to be minimal
for the 4 questionnaires, suggesting that they all would be
feasible in clinical practice. Most of the studies that have
evaluated the internal consistency have observed a Cron-
bach’s alpha greater than 0.90, suggesting that some of the
items could be redundant. The QuickDASH (a shorter
629
ASES DASH SPADI SST
2.13/1.81 1.19/1.22 2.10/1.72
1.60/1.35 1.62/1.22 2.12/1.71
2.10/1.73 0.99/1.10 1.77/1.51
0.93 1.23 0.87
1.13 0.95
1.44 1.13
0.54 0.71
1.63 1.79
⫺1.19 ⫺0.73
1.06/1.08 1.21/1.08
10.2 13.1
version of 11 items from the original DASH [62]) has been
shown to have a Cronbach’s alpha of less than 0.90 (range
0.88 – 0.89) (63,64), with the same level of reliability as the
full-length DASH (62).
Based on these psychometric properties, there is no
substantial evidence to recommend one questionnaire
over the others. This is particularly true when considering
that instruments may be used for different purposes. For
example, one instrument might be better for evaluating
change over time, whereas another might be better able to
discriminate between groups. To summarize the relative
benefits/limitations of different scales, a summary table
(Table 4) has been provided. This should assist in appro-
priate questionnaire selection and interpretation. Some
would argue that the DASH should be dismissed since it is
not shoulder specific. There is a general perception that
specific instruments are more responsive than generic.
However, the psychometric properties of the DASH are as
good as, if not better than, those of the shoulder-specific
scales reviewed. The SST should not be the first scale
chosen to evaluate change over time, because of the yes/no
response type and the fact that its absolute measurement
errors and MCID are still unknown. Considering their low
levels of absolute measurement errors, the DASH and the
ASES are recommended over the SPADI and the SST in
clinics or studies when various shoulder disorders are
evaluated. Based on their constructs, the ASES followed
by the SPADI is recommended if shoulder pain and phys-
ical function are specifically being evaluated, whereas if
clinicians or researchers also wish to evaluate emotional
and social function, then the DASH is recommended.
The evidence for properties such as relative reliability,
construct validity, and responsiveness are generally favor-
able for the reviewed scales. However, there are gaps in
defining benchmarks that are more useful in the clinic,
such as known group validity, SEM, MDC, and MCID.
630
These parameters should be assessed in people with dif-
ferent shoulder diagnoses, because this would be impor-
tant to 1) assist clinicians in determining the amount of
change that is clinically relevant, 2) set short- and long-
term goals, and 3) communicate more effectively with
payers.
Previous reviews have not included informal critical
appraisal of individual studies. Perhaps this is because of
a lack of critical appraisal instruments for psychometric
studies. One author (JCM) has developed an instrument for
critical appraisal of individual studies evaluating psycho-
metric properties of clinical measurements (11). By using
the instrument, we were able to contribute new informa-
tion to the quality of individual studies. Our high interra-
ter reliability prior to consensus indicates that the tool is
reproducible. Based on our detailed critical appraisal, we
were able to identify the most common flaws in current
research. From this, we recommend that future studies on
psychometric properties 1) specifically state hypotheses
that are to be evaluated, 2) calculate and justify the sample
size used, and 3) use specific error estimates such as con-
fidence intervals or SEM.
Because the studied populations were heterogeneous, it
was not possible to perform a true meta-analysis. There-
fore, we chose to average some psychometric properties
across studies by weighting the estimates reported based
on the study sample size as a means of synthesizing cur-
rent estimates into a more stable estimate. A limitation in
this approach is that settings, populations, and interven-
tions varied across studies and these results might not be
considered appropriate for pooling. A second limitation is
that 9 articles had to be excluded because only publica-
tions written in English or French were included. Finally,
we examined only 4 shoulder disability questionnaires
and cannot exclude the possibility that a superior ques-
tionnaire exists. Future systematic reviews might consider
other shoulder questionnaires when an appropriate quan-
tity of evidence becomes available.
In conclusion, the ASES, DASH, SPADI, and SST are
reliable, valid, and responsive across a number of shoulder
pathologies, including nonsurgical (shoulder pain, tendi-
nosis, impingement, osteoarthritis, frozen shoulder) and
surgical patients (rotator cuff repair, arthroplasty). The
ASES and the SPADI are recommended for patients fol-
lowing shoulder arthroplasty (58). Their respective MDCs
are approximately 9 and 18 for patients with various
shoulder disorders (13,42,52), whereas their respective
MCIDs are approximately 6.4 points and 8 points (40,42).
The DASH is the most extensively studied questionnaire
and is available in 16 languages. Its MDC is on average 10.5
for patients with various upper extremity disorders
(19,32,52), with an MCID of approximately 10 points (52).
In addition to the ASES, the DASH is the questionnaire
with the lowest absolute measurement error (52). The SST
is a highly reliable questionnaire and the quickest to
complete. However, its MDC and MCID have not been
defined. These measurement properties are needed in or-
der to determine the amount of change that is clinically
relevant.
Roy et al
AUTHOR CONTRIBUTIONS
Dr. Roy had full access to all of the data in the study and takes
responsibility for the integrity of the data and the accuracy of the
data analysis.
Study design. Roy, MacDermid.
Acquisition of data. Roy, MacDermid, Woodhouse.
Analysis and interpretation of data. Roy, MacDermid, Wood-
house.
Manuscript preparation. Roy, MacDermid, Woodhouse.
Statistical analysis. Roy, MacDermid.
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