Examining the Disabilities of the Arm, Shoulder, and Hand outcome instrument in extended reality: X-DASH

Patient-reported outcome measures (PROMs) rely on individual interpretation of questions and recall ability, which limits their standardization. We developed an extended reality (XR) PROM, transforming questions from the Disabilities of the Arm, Shoulder, and Hand (DASH) measure into standardized tasks and assessed its usability, validity, and reliability (X-DASH). We hypothesized that the X-DASH would show equivalent preliminary validity and reliability as conventionally administered DASH questions (C-DASH).

The X-DASH simulated 6 activities corresponding to the DASH questionnaire (jar opening, key turning, surface cleaning, back washing, bread cutting, and hammering) and was evaluated in 2 phases. In phase 1, usability was assessed with 20 healthy subjects using the System Usability Scale. In both phases, versions of the questionnaire were delivered conventionally via computer (C-DASH) and using X-DASH. Phase 2 included 40 patients with documented shoulder pathology using a randomized, cross-sectional design.

Phase 1: X-DASH scores were significantly higher (ie, worse) than C-DASH scores (P = .019), specifically due to item 4 (wash your back). No subjects reported higher scores in C-DASH. System Usability Scale scores showed good usability. Phase 2: Composite scores for the C-DASH were higher on average than X-DASH (P < .001). The structural validity of each showed a similar average variance explained (57%, 50%). Order of administration (C-DASH or X-DASH given first) had negligible effects. Twelve patients had large score discrepancies (composite score difference > ±10). Five patients were significantly more likely to select extreme responses ('unable' or 'extreme') in the C-DASH format (P = .009). For items 3 and 6 (with XR tasks) and items 7 and 10 (without XR tasks), significantly more participants scored higher on the C-DASH than the X-DASH (items 3 and 6: P < .001; item 7: P = .036; item 10: P = .035). C-DASH and X-DASH demonstrated similar measurement reliability. All patients reported that the XR system was easy to use.

To our knowledge, this is the first study to evaluate XR-based PROM delivery. The X-DASH shows similarities to C-DASH in our proof of concept, though scoring differences compared to C-DASH warrant further investigation.