To the Editors:

We thank Dr. Padua and colleagues for their interest in our systematic review. We strongly agree that cross-cultural validation of any translated self-report measure, in addition to excellent linguistic translation, is essential since measuring the patient perspective should not be restrictive. Translated questionnaires must be culturally adapted to insure content validity at a conceptual level, before they are used across different cultures (Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000;25:3186–91).

In our opinion, the translation/cross-cultural validation process is a reason to favor the DASH over other region- or shoulder-specific scales for use in clinical practice and research. Of the 4 questionnaires reviewed (the American Shoulder and Elbow Surgeons score, DASH, the Shoulder Pain and Disability Index, and the Simple Shoulder Test), only the DASH has an established, standardized process for translation/cross-cultural validation that requires written permission to proceed with the translation and use of specific translation guidelines to perform a translation/cross-cultural adaptation of the scale. These guidelines have been published by Beaton et al and are available on the Web site for the DASH outcome measure (URL:

Six specific stages (1) are recommended when performing a translation/cross-cultural adaptation of the DASH: 1) initial translation: 2 bilingual translators of different professional backgrounds, whose mother tongue is the target language, produce independent translations; 2) synthesis of the translation: the translators and a recording observer sit down to synthesize the results of the translations in order to reach consensus; 3) back translation: 2 translators, working from the target language version of the questionnaire and totally blind to the original version, translate the questionnaire back into the original language; 4) expert committee: the expert committee consolidates all the versions of the questionnaire and develops what would be considered the prefinal version of the questionnaire for field testing; 5) test of the prefinal version: 30–40 subjects complete the questionnaire and are interviewed about what they thought was meant by each questionnaire item and the chosen response; and 6) submission of documentation to the developers: submission of all the reports and forms are submitted to the Institute of Work & Health to verify that the recommended stages were followed.

The DASH is already widely used in the literature. As of December 2009, approved versions of the DASH were freely available in 27 languages (and 6 versions were in progress) on the Web site of the DASH outcome measure. Making the validated versions of the questionnaire freely available facilitates their use, which will ultimately lead to better benchmarking between studies. We consider that the process used by the DASH developers might serve as an exemplar for other tool developers whose scales may contribute to health measurement, including those who have developed shoulder-specific scales.

Jean-Sébastien Roy PT, PhD*, Joy C. MacDermid PT, PhD†, Linda J. Woodhouse PT, PhD‡, * McMaster University, Hamilton, Ontario, Canada, † McMaster University, Hamilton, Ontario, Canada, St. Joseph's Health Centre, London, Ontario, Canada, ‡ McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada, Holland Orthopaedic & Arthritic Hospital of Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.