musculoskeletal disorders are among the most frequently occurring chronic conditions that affect the general population and substantially impact physical activity , mental state , and quality of life ( qol ) ( bingefors and isacson , 2004 ; lawrence et al . , 1998 ) . musculoskeletal disorders become more prevalent with age , and they are the leading cause of disability ( lawrence et al . , 2008 ; picavet and hazes , 2003 ) . the management goals of patients with musculoskeletal disorders are no longer limited to reducing signs and symptoms but now includes increasing function ( dieppe , 2004 ) . there is a current trend to enhance general well - being or qol , which involves integrating patient - centric perspectives and comprehensive assessment of intervention outcomes ( furner et al . a growing number of outcome instruments have been introduced to evaluate upper limb function and disability ( oh et al . , 2009 ; romeo et al . , 1996 these instruments range from objective measures , such as range of motion ( rom ) ( constant and murley , 1987 ) or muscle strength ( constant and murley , 1987 ; roh et al . , 2012e ) , to more subjective measures , such as patient satisfaction ( monnin and perneger , 2002 ) or quality of life ( goldhahn et al . impairments such as muscle weakness or limitation in range of motion may have a comprehensive impact on daily life . for instance , grip strength has a critical role during the performance of daily activities , and is considered an important measure of recovery after upper extremity injuries and for the evaluation of treatment outcomes . however , the degree of satisfaction regarding function or disability differs across patients , and this inter - patient variability in self - assessment is important to consider in the clinical evaluation of upper limb function . in clinical studies , recent trend has been to move toward patient - based ( patient - centric ) instruments and away from clinician - based ( performance based ) ones , the letter of which is more susceptible to observer bias and error and does not represent illness / disability experience of patients themselves ( harvie et al . , 2005 ) . furthermore , outcome assessments include measures of impairment or disability as well as measures of general health - related qol , in order to assess the full impact of problem related to a certain upper limb condition . the purpose of this paper is to review outcome measures of upper limb function , which can be categorized as patient- or clinician - based , and as condition specific or general health related qol evaluations . in addition , we discuss clinical research considerations in selection / interpretation of instruments for upper limb functions . the upper limb outcome instruments reviewed in this article include the michigan hand questionnaire ( mhq ) , the patient - rated wrist evaluation score ( prwe ) , the constant - murley score , the simple shoulder test ( sst ) the oxford shoulder score ( oss , ) the disability of arm , shoulder and hand questionnaire ( dash ) , and the short form- 36 health survey ( sf-36 ) . on one hand , condition - specific instruments of musculoskeletal disorders measure symptoms and disabilities relevant to specific conditions and are useful for assessing responses to treatments . on the other hand , general health status instruments measure multiple aspects of health , including physical function , mental health , and social function . although generic measures may not be as sensitive to the disability experienced by patients , general health status measurements generally correlate with condition - specific instruments that address musculoskeletal manifestation ( ostendorf et al . this implies that musculoskeletal complaints influence general health status and that a considerable proportion of variation in general health status can be attributed to regional musculoskeletal disability . the michigan hand questionnaire ( mhq ) is a hand specific and patient - based subjective assessment ( chung et al . , 1998 ) . the questionnaire assesses a patient s perception to function , pain , satisfaction , and aesthetic appearance . the original mhq has been used with almost all types of hand disorders , and its reliability , validity , and responsiveness has been validated for a range of upper extremity conditions , such as carpal tunnel syndrome , distal radius fractures , and rheumatoid arthritis ( chatterjee and price , 2009 ; kotsis et al . , 2007 ; the questionnaire itself consists of 57 items , and distinguishes between left and right hands over six domains , including overall hand function , activities of daily living , pain , work performance , aesthetics , and patient satisfaction with function . each domain is scored from 0 to 100 , by which a lower score denotes worse disability save except for the pain domain for which the opposite holds true . the final score is obtained by averaging the six scores after reversing the pain score . patient - rated wrist evaluation score ( prwe ) is a reliable and valid tool for quantifying patient - rated wrist pain and disability in the setting of distal radius fractures treatment ( macdermid et al . , 1998 ) . the questionnaire is completed by the patient themselves and consists of two domains , pain and function . there are five items in the pain domain and ten items in the function domain . the pain score is the sum of five items , with the worst possible score of 50 , and the disability ( function ) score is the sum of ten items divided by 2 . the constant - murley questionnaire is a shoulder specific and clinician - based assessment with acceptable reliability and validity ( gilbart and gerber , 2007 ) , and is the most widely used questionnaire in europe ( kirkley et al . , 2003 ) . as the measurements are fundamentally different , the functional and physical examinations are scored separately , as opposed to being combined for a total score . the simple shoulder test ( sst ) is a patient - based measure ( lippitt , 1993 ) . it is a quick , subjective questionnaire composed of 12 questions with yes or no response . it was reported to be reliable , valid , and responsive ( godfrey et al . , 2007 ) . for each question , a patient indicates whether he or she is able to perform the indicated activity or not . the sum total score ranges from 0 ( worst ) to 12 ( best ) for shoulder function . oxford shoulder score ( oss ) ( dawson et al . , 1996 ) is a shoulder - specific , patient - based questionnaire composed of 12 questions for assessing pain perception and quality of life in patients with symptomatic pathologies of the shoulder . thus , it produces overall scores that range from 0 to 48 , with 48 being the best outcome . the oxford shoulder score is easy to complete , imposes very little burden to the patient , and provides reliable , valid , and responsive data about patient perceptions of shoulder problems ( christie et al . , 2009 ; kirkley et al . , 2003 ) it is an internationally recognized orthopedic assessment instrument , is available in certain european languages . . , 2012c ) the disability of arm , shoulder and hand ( dash ) is a self - administered , upper - extremity specific questionnaire that consists of 30 questions ( hudak et al . , 1996 ) . it includes physical functions , symptoms , and social function , work , sleep , and confidence items . five responses are provided per question and are scored from 1 ( without difficulty or no symptom ) to 5 ( unable to engage in activity or very severe symptom ) . thus , the dash provides the best possible score of 0 and the worst possible score of 100 . the dash evaluation is user - friendly , reliable , and valid for a range of upper - extremity disorders ( gummesson et al . , 2003 ; szabo , 2001 ) , and is the best instrument for evaluating patients with disorders involving multiple upper limb joints . the short form - 36 ( sf-36 ) health survey is the most widely used , patient - reported generic health status measure ( ware and sherbourne , 1992 ) . the 36 items in the questionnaire are grouped by eight health subscales which are designed to represent the world health organization definition of health : physical function ( pf ) , role limitations due to physical problems ( rp ) , bodily pain ( bp ) , general health ( gh ) , vitality ( vt ) , social function ( sf ) , role limitations due to emotional problems ( re ) , and mental health ( mh ) . these eight scales can be combined into two summary measures that provide overall estimates of physical health ( physical component summary [ pcs ] ) and mental health ( mental component summary [ mcs ] ) . the sf36v2 uses norm - based scores , and the its summary scores use the sum of eight subscale z - scores weighted by factor score coefficients ( ware , 2000 ) . the sf-36 is commonly used to represent broad aspects of health for questionnaire validation and reportedly is more responsive than other general health instruments for musculoskeletal disorders ( beaton et al . , 1996 ) . the michigan hand questionnaire ( mhq ) is a hand specific and patient - based subjective assessment ( chung et al . , 1998 ) . the questionnaire assesses a patient s perception to function , pain , satisfaction , and aesthetic appearance . the original mhq has been used with almost all types of hand disorders , and its reliability , validity , and responsiveness has been validated for a range of upper extremity conditions , such as carpal tunnel syndrome , distal radius fractures , and rheumatoid arthritis ( chatterjee and price , 2009 ; kotsis et al . , 2007 ; roh et al . , 2011 the questionnaire itself consists of 57 items , and distinguishes between left and right hands over six domains , including overall hand function , activities of daily living , pain , work performance , aesthetics , and patient satisfaction with function . each domain is scored from 0 to 100 , by which a lower score denotes worse disability save except for the pain domain for which the opposite holds true . the final score is obtained by averaging the six scores after reversing the pain score . patient - rated wrist evaluation score ( prwe ) is a reliable and valid tool for quantifying patient - rated wrist pain and disability in the setting of distal radius fractures treatment ( macdermid et al . , 1998 ) . the questionnaire is completed by the patient themselves and consists of two domains , pain and function . there are five items in the pain domain and ten items in the function domain . the pain score is the sum of five items , with the worst possible score of 50 , and the disability ( function ) score is the sum of ten items divided by 2 . the constant - murley questionnaire is a shoulder specific and clinician - based assessment with acceptable reliability and validity ( gilbart and gerber , 2007 ) , and is the most widely used questionnaire in europe ( kirkley et al . , as the measurements are fundamentally different , the functional and physical examinations are scored separately , as opposed to being combined for a total score . the simple shoulder test ( sst ) is a patient - based measure ( lippitt , 1993 ) . it is a quick , subjective questionnaire composed of 12 questions with yes or no response . it was reported to be reliable , valid , and responsive ( godfrey et al . , 2007 ) . for each question , a patient indicates whether he or she is able to perform the indicated activity or not . the sum total score ranges from 0 ( worst ) to 12 ( best ) for shoulder function . oxford shoulder score ( oss ) ( dawson et al . , 1996 ) is a shoulder - specific , patient - based questionnaire composed of 12 questions for assessing pain perception and quality of life in patients with symptomatic pathologies of the shoulder . thus , it produces overall scores that range from 0 to 48 , with 48 being the best outcome . the oxford shoulder score is easy to complete , imposes very little burden to the patient , and provides reliable , valid , and responsive data about patient perceptions of shoulder problems ( christie et al . , 2009 ; kirkley et al . , 2003 it is an internationally recognized orthopedic assessment instrument , is available in certain european languages . the disability of arm , shoulder and hand ( dash ) is a self - administered , upper - extremity specific questionnaire that consists of 30 questions ( hudak et al . , 1996 ) . it includes physical functions , symptoms , and social function , work , sleep , and confidence items . five responses are provided per question and are scored from 1 ( without difficulty or no symptom ) to 5 ( unable to engage in activity or very severe symptom ) . thus , the dash provides the best possible score of 0 and the worst possible score of 100 . the dash evaluation is user - friendly , reliable , and valid for a range of upper - extremity disorders ( gummesson et al . , 2003 ; szabo , 2001 ) , and is the best instrument for evaluating patients with disorders involving multiple upper limb joints . the short form - 36 ( sf-36 ) health survey is the most widely used , patient - reported generic health status measure ( ware and sherbourne , 1992 ) . the 36 items in the questionnaire are grouped by eight health subscales which are designed to represent the world health organization definition of health : physical function ( pf ) , role limitations due to physical problems ( rp ) , bodily pain ( bp ) , general health ( gh ) , vitality ( vt ) , social function ( sf ) , role limitations due to emotional problems ( re ) , and mental health ( mh ) . these eight scales can be combined into two summary measures that provide overall estimates of physical health ( physical component summary [ pcs ] ) and mental health ( mental component summary [ mcs ] ) . the sf36v2 uses norm - based scores , and the its summary scores use the sum of eight subscale z - scores weighted by factor score coefficients ( ware , 2000 ) . the sf-36 is commonly used to represent broad aspects of health for questionnaire validation and reportedly is more responsive than other general health instruments for musculoskeletal disorders ( beaton et al . , 1996 ) . to evaluate upper limb impairment or disability , reliable and validated outcome measures should take into account all aspects of a patient s life that may be affected by the presence of the disability or impairment . the former include items relevant and sensitive to the disorder being studied , and the latter allow for comparisons between conditions and may be sensitive to unexpected consequences of a disorder . all things being equal , the most responsive instrument available should be used in order to minimize the sample size for the proposed study . therefore , additional information is required to understand how sensitive these instruments are to clinical change in function experienced by patients who have problems over time . psychologic distress , such as pain - induced anxiety or depression , is increasingly recognized as contributing to pain and disability perception in several musculoskeletal disorders ( kim et al . , 2011 ; depression has been reported to be highly prevalent in the elderly and consistently contributes to symptom severity in some musculoskeletal disorders ( roh et al . 1991 ) furthermore , subjective factors , such as pain and depression , have been reported to have greater influences when disability is measured with respect to functions related to the entire upper extremity , i.e. dash scores , rather than with respect to a more specific regional site ( lindenhovius et al . , 2008 ) . a large variability in dash scores in upper - extremity disorders was found to arise from psychosocial rather than physical factors ( ring et al . , 2006 ) . female subjects are known to report higher level of musculoskeletal pain and disability , although objective findings , such as range of motion and abduction strength , did not differ between the genders ( roh et al . , 2012a ; roh et al . , 2012d ) musculoskeletal pain or disability has been reported to be both more prevalent ( leveille et al . , 2005 ) and worse in women ( bingefors and isacson , 2004 ) , which could be due to a higher physical vulnerability ( wijnhoven et al . , 2006 ) or sensitivity to pain ( wolfe et al . , 1995 ) in the gender . this gender - specific effect was reported not to be confined to a specific physical subscale but rather involved all physical components of sf-36 and dash . functional assessment is also influenced by the prevalence of degenerative musculoskeletal disorders such as osteoarthritis and rotator cuff disease . in individuals older than 65 yr , osteoarthritis of the knees and hands and rotator cuff diseases are the most prevalent causes of musculoskeletal pain . a high prevalence of these degenerative musculoskeletal diseases has been previously demonstrated ( picavet and hazes , 2003 ) , and prevalence of concurrent upper and lower extremity pain in those older than 65 yr is estimated to be greater than 40% ( scudds and robertson , 2000 ) . much progress has been made in validation of functional assessment of upper limb conditions , and currently there is a growing number of instruments for each of the main groups of upper limb conditions . the upper limb instruments reviewed in this article allow for assessments of various aspects of functional problems related to upper limb conditions . furthermore , functional outcome measures of upper limb are affected by differences in cultural , psychological , and gender aspects of illness perception and behavior . therefore , comprehensive assessment of upper limb function requires measures of impairment or disability as well as generic measures of health - related qol . standardized assessments of regional musculoskeletal disabilities and general health status may help clinician in treatment decision - making and in interpretation of treatment outcomes of upper limb conditions . clinicians and researchers should be aware of the characteristics of each outcome instrument and select the upper limb outcome instruments which most appropriately address the primary purpose of a given research .
musculoskeletal disorders substantially impacts physical activity , mental state , and quality of life ( qol ) . 
 generally , comprehensive assessment of upper limb function requires measures of impairment or disability as well as health - related quality of life . 
 a growing number of outcome instrument have been introduced to evaluate upper limb function and disability , and these measures can be categorized as patient- or clinician - based , and as condition specific or general health - related qol evaluations . 
 the upper limb outcome instruments reviewed in this article assess different aspect of upper limb conditions , and the measures are affected by differences in cultural , psychological , and gender aspect of illness perception and behavior . 
 therefore , physician should select / interpret the outcome instruments addressing their primary purpose of research . 
 information about regional instruments for upper limb condition and health - related qol in upper limb disorder may help us in decision - making for treatment priority or in interpretation of the treatment outcomes .