Workplace
ORIGINAL ARTICLE
1
Faculty of Rehabilitation
Medicine, University of Alberta,
Edmonton, Alberta, Canada
2
Department of Physical
Therapy, University of Alberta,
Edmonton, Alberta, Canada
3
Ted Rogers School of
Management, Ryerson
University, Toronto, Ontario,
Canada
Correspondence to
Dr Susan Armijo-Olivo, Faculty
of Rehabilitation Medicine,
University of Alberta,
Edmonton, Canada;
susanarmijo@gmail.com
Received 22 April 2016
Revised 27 July 2016
Accepted 9 August 2016
Published Online First
24 August 2016
▸ http://dx.doi.org/10.1136/
oemed-2016-103884
To cite: Armijo-Olivo S,
Woodhouse LJ, Steenstra IA,
et al. Occup Environ Med
2016;73:807–815.
Predictive value of the DASH tool for predicting
return to work of injured workers with
musculoskeletal disorders of the upper extremity
Susan Armijo-Olivo,1 Linda J Woodhouse,2 Ivan A Steenstra,3 Douglas P Gross2
ABSTRACT
Objectives To determine whether the Disabilities of What this paper adds
the Arm, Shoulder, and Hand (DASH) tool added to the
predictive ability of established prognostic factors,
▸ Only a few studies have investigated prognostic
including patient demographic and clinical outcomes, to
factors for upper extremity disorders, with a
predict return to work (RTW) in injured workers with
focus on prognostic factors related to disability
musculoskeletal (MSK) disorders of the upper extremity.
in general not on return to work (RTW).
Methods A retrospective cohort study using a
▸ To the best of our knowledge, there has not
population-based database from the Workers’
been any previous study looking at the
Compensation Board of Alberta (WCB-Alberta) that
predictive validity of the arm, shoulder and
focused on claimants with upper extremity injuries was
hand outcome measure (the Disabilities of the
used. Besides the DASH, potential predictors included
Arm, Shoulder, and Hand, DASH) tool to
demographic, occupational, clinical and health usage
determine RTW in injured workers.
variables. Outcome was receipt of compensation benefits
▸ We found that the DASH tool together with
after 3 months. To identify RTW predictors, a purposeful
other established predictors significantly helps
logistic modelling strategy was used. A series of receiver
to predict RTW after 3 months in patients with
operating curve analyses were performed to determine
upper extremity musculoskeletal (MSK)
which model provided the best discriminative ability.
disorders. An appealing result for clinicians and
Results The sample included 3036 claimants with
busy researchers is that DASH item 23 has
upper extremity injuries. The final model for predicting
equal predictive ability to the total DASH score
RTW included the total DASH score in addition to other
when added to other established predictors.
established predictors. The area under the curve for this
▸ These results have clinical and research
model was 0.77, which is interpreted as fair
implications since condition-specific tools such
discrimination. This model was statistically significantly
as the DASH tool when added to other
different than the model of established predictors alone
established predictors could help predict RTW in
( p<0.001). When comparing the DASH total score
individuals with upper extremity MSK disorders.
versus DASH item 23, a non-significant difference was
▸ DASH scores could also potentially help guide
obtained between the models ( p=0.34).
clinicians in determining early interventions for
Conclusions The DASH tool together with other
those patients identified at risk to not RTW
established predictors significantly helped predict RTW
based on these measures.
after 3 months in participants with upper extremity MSK
disorders. An appealing result for clinicians and busy
researchers is that DASH item 23 has equal predictive
2% to 53% and the 12-month prevalence from 2%
ability to the total DASH score.
to 41% depending on the setting, definition and
classification used.4 In the working population, the
reported 12-month prevalence is even higher with
percentages ranging from 22% to 40%.5
INTRODUCTION In order to effectively manage MSK pain and
Musculoskeletal (MSK) disorders, ranked as the avoid or predict its progression, it is important to
second most costly illness in Canada, have an eco- identify its prognostic factors. Although several
nomic burden of $17 billion per year and account studies have identified some factors associated with
for 39% of long-term disability.1 In fact, MSK con- poor prognosis regarding MSK pain; most of these
ditions are the leading cause of severe long-term studies have focused on low back pain,6 neck pain7
pain and physical disability worldwide.1 2 Work or MSK pain in general.8 9 Only a few studies have
disability and inability to return to work (RTW) investigated prognostic factors for upper extremity
due to MSK pain has been identified as a complex, disorders,10–12 with a focus on prognostic factors
multidimensional problem associated with high related to disability in general, but they have not
compensation and treatment costs.3 focused on RTW. Previous prognostic studies for
Although it is difficult to precisely estimate the patients with upper extremity disorders have pro-
extent of upper extremity MSK pain, many people vided inconclusive results regarding predictive
suffer from arm, neck and shoulder symptoms. The factors. Most of the prognostic factors for recovery
point prevalence has been reported to range from from upper extremity disorders depend on specific
Armijo-Olivo S, et al. Occup Environ Med 2016;73:807–815. doi:10.1136/oemed-2016-103791 807
 Workplace
populations and outcomes of interest.11 13 14 In addition, other
studies have emphasised that social and psychological factors at
work have been associated with greater lost time from work in
patients with arm, neck and/or shoulder symptoms who seek
physical therapy (PT) treatment.11 12 15
For example, Kennedy et al11 investigating predictors of dis-
ability in patients with shoulder soft tissue disorders found that
predictors of greater disability at discharge after PT treatment
included higher initial disability, therapist prediction of
restricted activities at discharge, workers’ compensation claim,
older age and being female. Predictors of greater improvement
in disability were shoulder surgery, higher pain intensity, shorter
duration of symptoms, younger age and poorer general physical
health.
We only found one study that used the Disabilities of the Arm
Shoulder and Hand (DASH) scores as a predictor of RTW in
workers with upper extremity disorders.16 This study high-
lighted that total DASH score was the only significant predictor
of RTW when compared with other physical factors such as
hand grip, manual dexterity, static strength and participant
characteristics such as age and gender. This study only included
a few physical and demographic factors in a small sample size of
workers with upper extremity disorders (n=52) and thus the
evidence is limited regarding the usefulness of DASH scores as a
prognostic factor for recovery from upper extremity disorders.
Of interest, Henschke et al9 found that generic factors appear
to play an important role in the prognosis of acute and chronic
non-spinal MSK pain, regardless of the location of pain. They
found that the most consistent predictors of poor outcome were
having the same symptom in the previous year, a lower level of
education, lower scores on the Short Form Health Survey
(SF-36) vitality subscale, using pain medication at baseline and
being bothered by the symptom more often in the past
3 months. However, pain location variables only slightly
improved the predictive ability of the models over the generic
factors and were inconsistent across the models. These authors
claimed that general participants’ characteristics and simple
general measures could suffice to determine who is going to
have a poorer outcome among participants with non-spinal
MSK pain. Thus, it could be theorised that general character-
istics and general tools used to assess pain and disability in
workers might be sufficient to predict poorer outcome in parti-
cipants with non-spinal MSK pain. Whether these generic prog-
nostic factors can be used to predict RTW for participants with
upper extremity injury is unclear. The value of adding disease
or function-specific tools, such as the DASH questionnaire,17 18
to improve this prediction also remains unknown. This
approach would also reduce patient (clinic) and research partici-
pant burden by avoiding filling out unnecessary questionnaires.
This will not only streamline but should improve data collec-
tion, as patients often lose focus or engagement when asked to
complete lengthy questionnaires which leads to altered
responses, skipped questions or incomplete questionnaires.19
Thus, the objective of this study was to determine whether
the DASH tool improved the ability to predict RTW beyond
generic prognostic factors such as patient characteristics, pain
intensity (measured with the visual analogue scale (VAS)), levels
of disability (measured with the Pain Disability Index (PDI)) and
health-related quality of life as scored on the SF-36 in injured
workers with upper extremity MSK disorders. We tested the
hypothesis that the DASH tool added predictive value to these
generic prognostic factors. We also examined whether item 23
of the DASH tool, a question that deals specifically with work,
was better than the total DASH score at predicting RTW (after
808 Armijo-Olivo S, et al. Occup Environ Med 2016;73:807–815. doi:10.1136/oemed-2016-103791
3 months) in injured workers with upper extremity MSK
disorders.
METHODS
Research design
A retrospective cohort study was used to identify prognostic
factors for receiving wage replacement benefits (WRB) 3 months
after having a comprehensive RTW assessment. Within the juris-
diction, claimants are sent for a comprehensive work/clinical
assessment after undergoing required primary care treatment in
the community (ie, physician, PT or chiropractic care), but
failing to RTW after a course of acute treatment. Claimants are
systematically referred for work/clinical assessment based on a
care pathway when they have not recovered within the antici-
pated healing time of their injury (typically between 4 and
8 weeks). These claimants are assessed to (1) determine their
readiness to RTW, (2) identify barriers to recovery and/or (3) be
triaged to the most appropriate type of rehabilitation. This
study was conducted on a population-based database created
from clinical and administrative claims data from the Workers’
Compensation Board of Alberta (WCB-Alberta).20 This data set
includes information on workers (workers’ compensation clai-
mants) experiencing work-related upper extremity MSK injuries
in the province of Alberta, Canada, who underwent a compre-
hensive RTW assessment and/or received rehabilitation. The
University of Alberta’s Health Research Ethics Board approved
this research.
Study population
Data were available on 8003 workers’ compensation claimants
who received rehabilitation for predominately subacute MSK
injuries between 1 December 2009 and 1 January 2011. This
study focused on those participants who had any injury of the
upper extremity (n=3036) as defined by relevant diagnostic clas-
sification codes (International Classification of Diseases (ICD)9).
The ICD9 codes referring to upper extremity were as follows:
fractures, dislocations, sprains/strains, lacerations, contusions,
nerve damage, joint disorders, other and unknown. Specific
codes included are available on request from the authors.
The database contains information on all workers across the
province undergoing rehabilitation. Of these with upper extrem-
ity disorders, 1557 (51.4%) were working but continuing to
experience disability due to their upper extremity disorders.
Since worker’s compensation is mandatory for most industries
and is administered on a provincial basis in Alberta, these data
are representative of practically the entire population of injured
workers. Within the province, claimants are sent for a compre-
hensive RTW assessment if, after undergoing required primary
care treatment in the community for a course of acute treatment
(ie, physician, PT or chiropractic care), they fail to RTW. Based
on the model of care described by Stephens and Gross,21 clai-
mants are referred for a work/clinical assessment following pre-
established evidence-based care pathways when they have not
recovered within the anticipated healing time of their injury
(typically between 4 and 8 weeks). Our research group has pre-
viously studied the comprehensive RTW assessment and the
tools used to assess a worker’s ability to RTW.20 In the case of a
claimant with more than one claim, only the first claim was
included. Claimants with missing data were omitted.
Measures
Dependent variable
The outcome for this study was receiving total or partial tem-
porary disability WRB 3 months after the comprehensive RTW

assessment. This outcome was used to indirectly determine
RTW, since participants receiving WRB would not be eligible to
RTW at the time of the follow-up. The same approach has been
used by other authors in similar studies using compensation clai-
mants.22 The timeline of 3 months was chosen as a key point in
recovery for injured workers as it has been found that injured
workers who cannot RTW within 3 months are likely to con-
tinue to experience work disability until at least 15 months.8
The outcome was dichotomous and was defined as follows:
‘no wage replacement’ or ‘wage replacement’.
No wage replacement meant that the claimant at 90 days after
discharge from the comprehensive RTW assessment was not
receiving any type of compensation due to total or partial tem-
porary disability. The claimant had returned to work and was
working in a full-time job.
Wage replacement meant that the claimant was continuing to
receive compensation payments due to total or partial tempo-
rary disability. The claimant was either working in a modified
part-time capacity (due to partial temporary disability) or not
working at all due to the work injury.
Independent variables
As per previous publications from our team,20 23 the database
used for this study contains information on a variety of poten-
tial prognostic factors that were included in the present study.
The data collected were determined based on a biopsychosocial
framework and earlier reports of potential effects on RTW and
work disability.24 25 Specific to this study, the database included
the following factors:
A. Individual demographic and social factors (eg, age, gender,
marital status, educational level, urban/rural status),
B. Occupational factors (eg, occupational category, employ-
ment and working status, modified work availability),
C. Health/injury factors (eg, previous injuries, self-rated health
status),
D. Healthcare usage (eg, number of visits to primary care provi-
ders) and
E. Clinical outcomes (eg, SF-36, the pain VAS, PDI, the DASH
tool and item 23 from DASH tool).
SF-36: This is a well-known tool to evaluate health-related
quality of life.26 Its validity has been established in an injured
population27 and it has been used in studies with MSK disorders
and occupational disability.28 29 The SF-36 includes eight health
domain scales including physical functioning, physical role func-
tioning, mental health, emotional role functioning, social role
functioning, general health perception, vitality and bodily pain.
Higher SF-36 scores indicate a more favourable health-related
quality of life.
VAS: This is a common and well-known tool to measure pain
intensity. Validity and reliability of the scale have been demon-
strated in a working population.30 The pain VAS tool consists of
a scale ranging from 0 to 10, where 0 means no pain and 10
means the most severe pain. In this measure, the claimant is
asked to mark his/her pain severity level on a 10 cm horizontal
line. A higher score means more pain intensity.
PDI: This is a self-report questionnaire that is commonly used
to measure the level of disability associated with pain.31 Its con-
current reliability and test–retest validity was found to be
acceptable in several different populations.32 33 The PDI
includes seven areas: recreation, family and home, social, occu-
pation, sexual relations, self-care and life support activities.
Respondents are asked to rate their disability level due to pain
in each of the seven areas where 0=no disability and 10=the
worst disability. Since the sexual relations item is commonly
Armijo-Olivo S, et al. Occup Environ Med 2016;73:807–815. doi:10.1136/oemed-2016-103791
Workplace
missing, overall PDI in percentage (%) was calculated with
higher scores indicative of greater disability.
DASH tool: The DASH outcome measure is a questionnaire
designed to be used for single or multiple disorders of the
upper limb, providing the possibility of a single questionnaire
for measuring disability for any upper limb region.17 Its validity,
reliability and responsiveness have been established.18 34 The
intent is that the DASH be used no matter what region or
regions are affected. The DASH is a 30-item questionnaire that
evaluates symptoms and physical function (at the level of dis-
ability), with a five response options for each item. At least 27
of the 30 items must be completed for a score to be calculated.
The assigned values for all completed responses are simply
summed and averaged, producing a score out of five. This value
is then transformed to a score out of 100 by subtracting 1 and
multiplying by 25. This transformation is done to make the
score easier to compare to other measures scaled on a 0–100
scale. A higher score indicates greater disability. Item 23 of the
DASH tool deals specifically with work. This item asks: ‘During
the past week, were you limited in your work or other regular
daily activities as a result of your arm, shoulder or hand
problem?’ Both the overall score and the score on item 23 were
considered as potential predictor variables in our analysis. Since
item 23 is work-related, we hypothesised that it may have a
comparable or better prognostic value than the rest of the
DASH tool.
Data analysis
Data on prognostic factors were analysed descriptively based on
participants returning or not returning to work. Means, fre-
quencies and proportions were computed for each group
depending on specific prognostic factor. To identify the signifi-
cant predictive/prognostic factors for long-term work disability
(ie, predict that WRB would be necessary at 3 months) a mul-
tiple logistic regression analysis was used since the main depend-
ent variable was dichotomous.
A purposeful modelling strategy was followed.35 First, uni-
variate regression was performed separately to examine each
potential prognostic factor. The independent variables that were
significant at p≤0.20 were entered into a multiple logistic regres-
sion model. Next, variables that were not statistically significant
at p<0.05 were removed. The continuous variables in the
interim model were tested for potential violation of the linearity
assumption and multicollinearity. The continuous variables,
which violated the linearity assumption, were categorised (eg,
prior claims, PT visits). The final model included all variables
that were statistically significant. A series of receiver operating
characteristics (ROC) were performed to determine which
model would provide the best discriminative ability regarding
receiving WRB or not. The main ROC analysis was performed
to determine whether the model including generic predictors
(demographics plus generic tools to evaluate pain and disability)
plus the DASH tool was better than the model including generic
predictors alone. The ROC analysis provides the area under the
curve (AUC) which is an overall measure of discrimination; that
is, it identifies how accurately the model can correctly classify
participants as receiving or not receiving WRB. The most useful
model can then be identified by comparing the AUC, where
models with higher AUC values are better at discriminating
between groups.36 37 The following guidelines are recom-
mended for interpreting the discrimination performance of a
model from the AUC: excellent discrimination (AUC=0.90–
1.0); good discrimination (AUC=0.80–0.90); fair discrimination
(AUC=0.70–0.80); poor discrimination (AUC=0.60–0.70) and
809
 Workplace
discrimination no better than chance (AUC≤0.50).38 A sensitiv-
ity analysis was conducted running the same models but limiting
the sample to only those individuals who were receiving any
benefits (total or partial temporary disability WRB) at assess-
ment. The STATA software V.14 (StataCorp. 2014. Stata
Statistical Software: Release 14. College Station, Texas, USA:
StataCorp LP) was used to determine the OR and 95% CI for
each factor or level of a prognostic factor that was significant.
RESULTS
The cohort of claimants included 3036 workers with upper
extremity injury. Of those, 558 participants had missing data on
DASH scores. There were no significant differences in demo-
graphics, occupation, health/injury and healthcare usage factors
between participants with and without missing data on DASH
scores. The descriptive characteristics of the sample are dis-
played in table 1. Only a few of the individual demographic and
social factors, occupational factors, health/injury factors, health-
care usage were significantly different between participants who
did and did not RTW. All of the clinical outcomes (SF-36, VAS
for pain, PDI, the DASH tool and item 23 of the DASH tool)
were statistically significant between the groups (ie, those who
did vs those who did not RTW). For example, those who did
not RTW had significantly lower SF-36 scores, higher levels of
pain (VAS), greater general disability associated with pain (PDI)
and higher disability related to upper extremity (DASH score).
In addition, a higher proportion of participants who did not
RTW reported ‘very limited’ or ‘unable to work’ due to arm,
shoulder or hand problem according to item 23 of the DASH
tool ( p<0.001).
The majority of the participants in this sample were between
the ages of 45 and 54 years (n=1010; 33.27%), male (n=1912;
62.98%), married (n=933, 30.73%), highly educated (n=777,
46.2%), lived in an urban area (n=2105, 69.33%), had a job
attached at admission (n=2611, 86%), had no comorbidities
(n=2175, 71.64%), had between 1 and 5 prior claims
(n=1523, 52.94%), and had ≤10 PT visits (n=1194, 39.33%).
Unadjusted ORs
The unadjusted ORs for each of the variables tested in the uni-
variate analysis for predicting wage replacement at 90 days are
shown in table 2. In general, age, education, geographical
region, job attached at admission, comorbidities, prior claims,
PT visits, time between accident and admission, availability of
modified work, SF-36, VAS, PDI, and DASH scores, and item
23 of DASH score were all significantly associated with receiv-
ing wage replacement at 90 days. All of these variables were
entered in the multiple logistic regression analysis modelling
(next stage). Thus, it can be said that individuals who are older,
have a job attached at admission, have a higher level of educa-
tion, have more comorbidities, more prior injury claims, more
PT visits, higher levels of pain (VAS), PDI and DASH scores
were more likely to receive WRB at 90 days. Conversely, indivi-
duals who live in urban areas, those in jobs where there is modi-
fiable work available, and those with higher SF-36 scores across
the different quality of life domains, were less likely to receive
WRB at 90 days.
Results from multiple logistic regression analysis
As aforementioned, all variables deemed to be significant in the
univariate analyses were included as independent variables in
the multiple logistic regression analysis modelling. Several
models were tested to determine the discriminative ability to
predict WRB at 90 days after assessment. The first model that
810 Armijo-Olivo S, et al. Occup Environ Med 2016;73:807–815. doi:10.1136/oemed-2016-103791
was tested was the multivariate model including the significant
variables related to demographics, occupational factors, health/
injury factors and healthcare usage. This model was called the
‘generic model’ and included the following independent vari-
ables: comorbidities, geographic location, PT visits, modified
work and prior injury claims. Age, education and time from
accident to admission (calendar days) were no longer significant
at α=0.05 and thus were eliminated from this model. The AUC
for the model that included demographics, occupational factors,
health/injury factors and healthcare usage (generic predictors)
was AUC 0.70, which can be interpreted as fair discrimination
(AUC=0.70–0.80). The second model included all variable in
this generic model plus the addition of pain VAS scores. This
resulted in a significant difference between the two models to
determine WRB at 90 days (χ2 (1)=17.94, Prob>χ2≤0.001),
with the model including pain VAS scores being superior.
A similar finding occurred when the PDI scores (third model),
SF-36 scores (fourth model) and DASH scores (fifth model)
were each added to the model of the generic predictors. The
AUC was increased to 0.75, 0.75 and 0.76, respectively
(p<0.001). However, there were no statistically significant dif-
ferences between the models that included pain VAS, PDI
scores, SF-36 scales or the DASH scores.
When all clinical outcomes ( pain VAS, PDI scores, SF-36
scores and DASH scores) were simultaneously added to the
model of generic predictors, the AUC reached 0.77. This was
significantly better (χ2 (1)=26.64; Prob>χ2<0.001) than the
model including only the generic predictors. However, this
model was not significantly different from the model that
included any one of the clinical variables (either pain VAS, PDI
scores, SF-36 scales or DASH scores). Thus, a sixth model was
developed including the generic predictors plus all of the clini-
cal outcomes. After including all variables in the model,
comorbidities, pain VAS and PDI were no longer significant and
thus were eliminated from the model. The final model included
three subscales of the SF-36 ( physical functioning, social
functioning and role physical), and the total DASH score in
addition to the generic predictors (demographics, occupational
factors, health/injury factors and healthcare usage). The AUC
for this final model was 0.77, which can be interpreted as fair
discrimination (AUC=0.70–0.80). This model was statistically
significantly better than the model of generic predictors (χ2 (1)
=21.47; Prob>χ2<0.001; figure 1).
When comparing the final model including DASH total score
versus the final model including only the item 23 from the
DASH tool, a non-significant difference was obtained between
the models to determine WRB at 90 days (χ2 (1)=0.91,
Prob>χ2=0.34). The areas under the curve were 0.77 and 0.76,
respectively, which can be interpreted as fair discrimination
(AUC=0.70–0.80). Sensitivity analysis indicated the same
results were obtained when limiting the sample to those receiv-
ing any, total or partial, temporary disability WRB at time of
assessment.
DISCUSSION
The objective of this research was to determine whether the
DASH tool added predictive ability to other known prognostic
factors (including patients’ demographic, occupational, health/
injury and healthcare usage factors) to predict RTW in injured
workers with upper extremity MSK disorders. In addition, we
wanted to determine if using only one item from the DASH
tool, a question about work disability, could be equally as effect-
ive at predicting RTW at 90 days in injured workers with upper
extremity MSK disorders. Results highlight that the DASH tool
 Workplace

Table 1 Descriptive characteristics of the sample of participants with upper extremity disorders by RTW status (receiving wage replacement
benefits at 90 days postassessment)
Claimants not receiving Claimants receiving WRB
WRB (RTW) (no RTW) Total

Variables Count (%) Count (%) Count (%) p Value

Age
16–24 185 6.85 13 3.87 198 6.52 0.108
25–34 512 18.96 54 16.07 566 18.64
35–44 625 23.15 78 23.21 703 23.16
45–54 896 22.19 114 33.94 1010 33.27
55–64 430 15.93 69 20.54 499 16.44
65–74 48 1.78 8 2.38 56 1.84
≥75 4 0.15 0 0 4 0.13
Gender
Female 994 36.81 130 38.69 1124 37.02 0.5
Male 1706 63.19 206 61.31 1912 62.98
Marriage status
Common in law 188 6.96 28 8.33 216 7.11 0.242
Divorced 114 4.22 16 4.76 130 4.28
Married 818 30.3 115 34.23 933 30.73
Separated 64 2.37 10 2.98 74 2.44
Single 428 15.85 53 15.77 481 15.84
Widowed 30 1.11 6 1.79 36 1.19
Not specified 1058 39.19 108 32.14 1166 38.41
Education
Junior level school 350 12.96 39 11.61 389 12.81 0.052
High school level 456 16.89 60 17.89 516 17
Superior level 672 24.89 105 31.2 777 25.59
Not specified 1222 45.26 132 39.29 1354 44.6
Geographic region
Rural 811 30.04 120 35.71 931 30.67 0.033
Urban 1889 69.96 216 64.29 2105 69.33
Working status at admission
Yes 1451 53.8 106 31.74 1557 51.4 <0.001
No 1244 46.2 228 68.26 1472 48.6
Job attached at admission
Yes 2317 85.81 294 87.5 2611 86 0.4
No 383 14.19 42 12.5 425 14
Receiving any WRB at admission
Yes 1298 48.07 274 81.55 1572 51.78 <0.001
No 1402 51.93 62 18.45 1464 48.22
Comorbidity
Yes 732 27.11 129 38.39 861 28.36 <0.001
No 1968 72.89 207 61.61 2175 71.64
Prior claims
0 642 25.05 58 18.47 700 24.33 0.012
1–5 1334 52.1 189 60.19 1523 52.94
≥6 587 22.9 67 21.34 654 22.73
Physical therapy visits
≤10 1119 41.44 75 22.32 1194 39.33 <0.001
11–20 855 31.67 69 20.54 924 30.43
≥21 726 26.89 192 57.14 918 30.24

Mean SD Mean SD

Time of accident to admission 203.6 374.3 251.5 414 0.02

SF-36
SF-36 physical functioning 67.69 19.24 58.17 19.51 <0.001
SF-36 BP bodily pain? 30.01 21.55 20.84 17.8 <0.001
SF-36 general health 69.17 18.88 65.56 18.95 <0.001
SF-36 vitality 53.45 20.81 47.37 21.38 <0.001
Continued

Armijo-Olivo S, et al. Occup Environ Med 2016;73:807–815. doi:10.1136/oemed-2016-103791 811

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Table 1 Continued
Claimants not receiving Claimants receiving WRB
WRB (RTW) (no RTW) Total

Variables Count (%) Count (%) Count (%) p Value

SF-36 social functioning 60.9 26.16 46.26 25.22 <0.001

SF-36 role emotional 62.57 32.02 49.18 33.2 <0.001
SF-36 mental health 65.01 21.07 57.26 22.41 <0.001
SF-36 role physical 36.13 27.43 21.47 21.08 <0.001
VAS 4.69 2.58 5.9 2.3 <0.001
Overall PDI 42.52 21.37 56.04 20.52 <0.001
DASH total score 40.75 20.18 53.22 19.72 <0.001

DASH item 23 Count (%) Count (%)

Not limited at all (reference) 162 7.17 3 1 165 6.47 <0.001

Slightly limited 467 20.67 35 12 502 19.68
Moderately limited 757 33.51 76 26 833 32.7
Very limited 662 29.31 120 41 782 30.7
Unable 211 9.34 58 19.9 269 10.54
DASH, Disabilities of the Arm, Shoulder, and Hand; PDI, Pain Disability Index; RTW, return to work; SF-36, Short Form Health Survey; VAS, visual analogue scale; WRB, wage
replacement benefits.

significantly contributes to the prediction of RTW. Even more
appealing for clinicians and busy researchers, item 23 from the
DASH tool (related specifically to work disability) has equal pre-
dictive ability as the total DASH score. These results suggest that
specific tools augment the predictive ability of generic predictors
of RTW for patients with upper extremity MSK disorders.
Prognostic factors for RTW in upper extremity disorders
Most prognostic studies performed on patients with upper limb
disorders have not focused on RTW as an outcome. Further,
DASH scores have not been evaluated as a prognostic factor for
RTW, rather DASH scores are typically evaluated as a predictor
of upper extremity disability. Most of the studies investigating
prognostic factors have used disease severity, upper limb per-
formance, disability and perceived recovery as outcomes. The
results of previous prognostic studies for upper extremity disor-
ders have been inconclusive, with no clear set of consistent pre-
dictive factors. The prognostic factors described in the literature
depend on specific populations and outcomes of interest.11 13 14
Social and work-related psychological factors have been asso-
ciated with sickness absence in patients with arm, neck and/or
shoulder symptoms undergoing PT.11 12 15 According to Bot
et al,15 both clinical characteristics and psychological factors
help predict the outcome of neck and shoulder symptoms.
However, according to others,14 the contribution of psycho-
logical factors to the course of disability of upper extremity dis-
orders has not yet been clearly addressed, thus their influence
remains unclear.
Focusing on studies of prognostic factors of RTW in indivi-
duals with upper extremity disorders, a review by Selander
et al39 found that demographic, psychological, social, medical,
rehabilitation-related, workplace-related and benefit system-
related factors are associated with RTW in participants with
neck, back and shoulder problems. Specifically, participants who
were younger, highly educated, with a steady job and high
income, married, with stable social networks, self-confident,
happy with life, not depressed, with low levels of disease sever-
ity, no pain, high work seniority, a long working history, and an
employer that cares and wants the employee back in the work-
place were more likely to RTW. Similar predictors have been
812
found in other studies that examined RTW in participants with
upper extremity disorders, such as carpal tunnel syndrome.22 40
These results suggest that a range of factors influence work
status among individuals with upper extremity disorders and
thus they support a multidimensional model of assessment and
treatment for these conditions.
As expressed previously, there is limited evidence regarding
prognostic factors of upper extremity disorders, especially when
trying to predict RTW using outcome measures such as the
DASH. Thus, our study results can only be directly compared
with a few studies. We found only two articles that examined
the DASH tool as a predictor of RTW. A study by De Smet13
found that in manual workers, shorter temporary disability
periods were significantly associated with lower DASH scores.
However, the authors of this study did not investigate the value
of DASH scores as a prognostic factor using a multiple regres-
sion analysis modelling to determine the individual contribu-
tions of different predictors, in addition to the DASH scores,
for predicting RTW status. Thus, the information provided by
this study is limited.
Only one recently published study that examined predictors
of RTW in workers with upper extremity disorders used DASH
scores as a predictor using a multiple logistic regression ana-
lysis.16 Total DASH score was found to be the only significant
predictor of RTW when compared with other physical factors
such as hand grip, manual dexterity, static strength and partici-
pant characteristics such as age and gender. Participants who
RTW had a significantly lower DASH score (26.6 points) than
those who did not RTW (55.7 points). Although the study by
Moshe et al16 only examined physical and demographic factors
in a small sample size of workers with upper extremity disorders
(n=52), and did not consider other psychosocial factors, it high-
lighted that the role of the DASH in determining those patients
at risk for delayed RTW in individuals with upper extremity dis-
orders. Our results are consistent with the findings from this
study, highlighting the predictive value of DASH scores in this
population. Mean values for DASH total score were higher in
our study for patients who RTW than those reported by Moshe
et al (40.75 vs 26.6 points). This difference could be due to dif-
ferences in the sample population studied in the respective
Armijo-Olivo S, et al. Occup Environ Med 2016;73:807–815. doi:10.1136/oemed-2016-103791
 Workplace

Table 2 Univariate and multivariate analyses for predicting wage replacement at 90 days in participants with upper extremity disorders
Multivariate analysis (DASH Multivariate analysis (item 23
Univariate analysis total score) DASH)
Outcome:
Include in
multivariate
Factors: receiving WRB OR 95% CI p Value model OR 95% CI p Value OR 95% CI p Value

Age
16–24 (reference) 1
25–34 1.5 0.97 to 2.81 0.21 Yes*
35–44 1.78 0.97 to 3.27 0.065
45–54 1.81 0.1 to 3.3 0.051
55–64 2.28 1.23 to 4.23 0.009
≥65 2.19 0.86 to 5.57 0.1
Gender
Female 1.08 0.86 to 1.37 0.5 No
Male (reference) 1
Marriage status
Single (reference) 1
Common in law 1.2 0.74 to 1.96 0.46 No
Divorced 1.13 0.62 to 2.06 0.47
Married 1.14 0.80 to 1.60 0.47
Separated 1.26 0.61 to 2.61 0.53
Widowed 1.62 0.64 to 4.06 0.31
Not specified 0.82 0.58 to 1.17 0.28
Education
Junior level school (reference) 1 Yes*
High school level 1.18 0.77 to 1.81 0.45
Superior level 1.4 0.95 to 2.07 0.09
Not specified 0.97 0.67 to 1.41 0.87
Geographic region
Rural 1 1
Urban 0.77 0.61 to 0.98 0.034 Yes 0.66 0.48 to 0.90 0.008 0.63 0.47 to 0.86 0.003
Admission job attached
Yes 1.16 0.82 to 1.63 0.4 No
No (reference) 1
Comorbidity
Yes 1.68 1.32 to 2.12 <0.001 Yes*
No (reference) 1
Prior claims
0 (reference) 1
1–5 1.57 1.15 to 2.14 0.004 Yes 1.69 1.15 to 2.47 0.007
≥6 1.26 0.87 to 1.83 0.214 1.08 0.68 to 1.72 0.73
Physical therapy visits
≤10 1 1
11–20 1.2 0.86 to 1.69 0.29 Yes 1.22 0.79 to 1.88 0.4 1.31 0.86 to 1.99 0.201
≥21 3.95 2.97 to 5.24 <0.001 4.2 2.93 to 5.95 <0.001 4.2 3 to 5.94 <0.001
Accident to admission 1 1 to 1 0.031 Yes*
Job attached at admission 1.15 0.82 to 1.63 0.4 No
Modified work available
No (reference) 1 1
Yes 0.65 0.51 to 0.82 <0.001 Yes 0.81 0.60 to 1.09 0.17 0.78 0.59 to 1.06 0.11
Unknown 0.34 0.18 to 0.72 0.004 0.36 0.15 to 0.87 0.023 0.42 0.19 to 0.96 0.04
SF-36
SF-36 physical functioning 0.98 0.97 to 0.98 <0.001 Yes 0.99 0.98 to 1 0.031 0.99 0.98 to 0.99 0.006
SF-36 BP bodily pain? 0.98 0.97 to 0.98 <0.001
SF-36 general health 0.99 0.98 to 0.99 0.002
SF-36 vitality 0.99 0.98 to 0.99 <0.001
SF-36 social functioning 0.98 0.97 to 0.98 <0.001 0.99 0.98 to 1 0.048 0.99 0.98 to 0.99 0.008
SF-36 role emotional 0.99 0.98 to 0.99 <0.001
SF-36 mental health 0.98 0.98 to 0.99 <0.001
SF-36 role physical 0.98 0.97 to 0.98 <0.001 0.99 0.98 to 1 0.031 0.99 0.98 to 0.99 0.04
Continued

Armijo-Olivo S, et al. Occup Environ Med 2016;73:807–815. doi:10.1136/oemed-2016-103791 813

 Workplace

Table 2 Continued
Multivariate analysis (DASH Multivariate analysis (item 23
Univariate analysis total score) DASH)
Outcome:
Include in
multivariate
Factors: receiving WRB OR 95% CI p Value model OR 95% CI p Value OR 95% CI p Value

VAS 1.21 1.15 to 1.27 <0.001 Yes*

Overall PDI 1.03 1.02 to 1.04 <0.001 Yes*
DASH total score 1.03 1.02 to 1.04 <0.001 Yes 1.01 1 to 1.02 0.01
Item 23 DASH score
Not limited at all (reference) 1 1
Slightly limited 4.1 1.22 to 13.33 0.022 Yes 2.61 0.76 to 8.89 0.124
Moderately limited 5.42 1.68 to 17.4 0.004 Yes 2.91 0.88 to 9.69 0.081
Very limited 9.79 3.07 to 31.18 <0.001 Yes 3.7 1.1 to 12.51 0.035
Unable 14.84 4.57 to 48.23 <0.001 Yes 4.7 1.33 to 16.65 0.016
Item 23 DASH score: During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem?
*No longer significant in multivariate model.
DASH, Disabilities of the Arm, Shoulder, and Hand; PDI, Pain Disability Index; RTW, return to work; SF-36, Short Form Health Survey; VAS, visual analogue scale; WRB, wage
replacement benefits.

studies. Our study involved a large database of workers, while
Moshe et al16 only included 52 patients, of whom 42% (n=22)
returned to work. This RTW percentage was much smaller than
the one observed in our sample, which was ∼89%. In addition,
according to the DASH score, participants in the Moshe et al16
study were less disabled in the upper extremity than those who
returned to work in our study. It may be that patients who
RTW in our sample still had some degree of ongoing disability.
As recommended by Moshe et al,16 healthcare professionals
working with patients who have upper extremity disorders
should consider a high DASH score as a warning sign when
assessing RTW in this population.
In addition, we found that DASH item 23, which deals only
with RTW, can be as effective in predicting RTW as the total
DASH score. This may provide efficiency for users of the DASH
who are most interested in predicting RTW. However, it is
recommended that these findings be confirmed in other settings.
Strengths
To the best of our knowledge, this is one of the few studies evalu-
ating the ability of the DASH to predict RTW in patients with
upper extremity disorders. We used a multivariable logistic model
approach and appropriate model building techniques,
strengthening results of this study. The analysis was performed
using a large database containing information on all workers
undergoing rehabilitation across the province of Alberta, Canada.
These data represent almost an entire provincial population of
injured workers with upper extremity disorders over the study
timeframe.
Limitations
One of the limitations of our study was the retrospective nature
of the design. Thus, this study is subject to the same limitations
as any other studies that analysed previously collected workers’
compensation data. These limitations include lack of control of
the variables available or quality of the data. We did not collect
data on RTW directly; instead, we used receiving total or partial
temporary disability WRB 3 months after the comprehensive
RTW assessment as an indirect measure of RTW. Thus, partici-
pants receiving partial temporary disability wage replacement
could be working in a modified part-time capacity (due to
partial temporary disability) and the definition of RTW used by
this study could underestimate the actual RTW. However, using
payment for partial or total temporary disability as a surrogate
for RTW has been used in previous studies of patients receiving
compensation and represents a meaningful outcome to insurers
and workers’ compensation boards.22 24 In addition, the data-
base used for this study did not include data on the DASH tool
work module, which prevented us from analysing the influence
of these items on RTW.
This study included all injured workers except for those with
missing data on DASH scores. However, there was no statisti-
cally significant difference in demographics, occupational,
health/injury and healthcare usage factors between injured
workers with missing DASH data and those without missing
data. Because of the limited evidence regarding prognostic
factors for upper extremity disorders, especially for RTW out-
comes, it is recommended that further research looks into the
impact of demographic, psychological, psychosocial factors and
employer factors39 on RTW preferably using prospective cohort
study designs in workers with upper extremity disorders.

Figure 1 ROC comparing the generic model versus the generic model CONCLUSION
plus the total DASH score. AUC, area under the curve; DASH, Disabilities The DASH tool predicted RTW after 3 months in patients with
of the Arm, Shoulder, and Hand; ROC, receiving operating curve. upper extremity MSK disorders, after controlling for other
814 Armijo-Olivo S, et al. Occup Environ Med 2016;73:807–815. doi:10.1136/oemed-2016-103791

established predictors. An appealing result for clinicians and
busy researchers is that a single DASH item (item 23—a ques-
tion related specifically to work disability) has equal predictive
ability as the total DASH score when added to other established
predictors. These results have clinical and research implications
since condition-specific tools could help to predict RTW in indi-
viduals with upper extremity MSK disorders.
Contributors SA-O and DPG provided concept/idea/research design and writing.
IAS and LJW provided feedback for concept/idea/research design and provided
writing. SA-O performed statistical analysis. All authors critically revised the final
version of the manuscript and provided final approval of the version to be published.
Funding The data for this study were obtained in a study funded by a research
grant from the Workers’ Compensation Board of Alberta. SA-O is funded by a
‘Music in Motion’ Fellowship from the Faculty of Rehabilitation Medicine.
Competing interests None declared.
Ethics approval University of Alberta Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
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