Recommended Measures for Joint Chronic GVHD: Results from the Chronic GVHD Consortium

Field: Medicine (Health Sciences)

Assessing the degree to which chronic GVHD (cGVHD) may limit range of joint motion (ROM) needs to be accomplished reliably, simply, and in a clinically meaningful way. We evaluated NIH recommended scales and a photographic ROM (P-ROM) scale [Carpenter PA, Blood 2011] for their correlation with provider (MD) and patient (PT) perceptions of joint change. As part of a multicenter, prospective, longitudinal observational cohort, 458 patients receiving systemic cGVHD therapy were studied; 177/327 (54%) with baseline P-ROM had limited ROM defined by any 1-6 P-ROM score (7 = full ROM) at the wrists, elbows, shoulders or, 1-3 score (4 = full) at the ankles. NIH cGVHD joint scoring was categorical: 0 = full ROM (or not limited by cGVHD) and scores 1 to 3 were based upon MD opinion of PT extremity tightness, degree of reduction in both ROM and activities of daily living. At follow-up visits, as anchors, PT and MD rated separately their perception of change in joint cGVHD. Multivariable models were used to measure associations between MD/PT perceived changes (improved, stable, worse) and changes in P-ROM measures, NIH joint scores, and other items in the 2005 NIH consensus recommendations. ROM limitation was common (see Table). It was seen in patients with a longer duration of cGVHD, and was associated (p<0.01) with NIH skin response measures, the NIH 0-3 joint score, Lee energy subscale but not the Human Activity Profile, 2-minute walk test or grip strength. Compared to previous visits with ROM limitation (N = 369 visits), both MDs (60%) and PTs (47%) were more likely to report perceived improvement than worsening (4% MD, 9% PT). In multivariable analyses, MD perceptions of change in joint cGVHD were best predicted by P-ROM wrist score (p = 0.003), NIH 0-3 joint score (p<0.001) and SF36 bodily pain subscale (p = 0.01). PT perceptions of changes in joint cGVHD were predicted by SF36 bodily pain score (p = 0.01). Changes in the extrapolated Rodnan skin score and the NIH 0-3 skin score were not associated with perceived changes in joint cGVHD by MD and PT. Joint involvement is common and should be assessed in all patients with cGVHD. The NIH joint score (1 item), P-ROM scale (4 items) and the SF36 bodily pain subscale (2 items) appeared to have the most clinical utility for measuring symptom change. Finer gradations within the P-ROM's clinically relevant range (scores 4-7) may improve its sensitivity to change.TableAnalysis of Categorical and Continuous Variables associated with ROMMeasuresROM involved (N = 177)ROM not involved (N = 150)P valueWrist P-ROM Score ("Prayer position")(%)7 (full)4010064005110430310230120Total involved600NA∗Comparisons for these measures are not meaningful because they are used to define joint involvement. Abbreviations: ROM, range of motion; BSA, body surface areaShoulder Abduction P-ROM Score (%)7 (full)5710062705120420310200110Total involved430NA∗Elbow Extension P-ROM Score (%)7 (full)691006200580420300210100Total involved310NA∗Comparisons for these measures are not meaningful because they are used to define joint involvement. Abbreviations: ROM, range of motion; BSA, body surface areaAnkle Dorsiflexion P-ROM Score4 (full)391003540270100Total involved610NA∗Comparisons for these measures are not meaningful because they are used to define joint involvement. Abbreviations: ROM, range of motion; BSA, body surface areaNIH Skin Response Measures (%BSA), Mean (SD)Erythema5.0 (15.6)9.7 (20.1).009Moveable sclerosis4.6 (10.3)0.8 (4.2)<.0001Non-moveable sclerosis3.1 (8.8)0.0 (0.0)<.0001Lee Energy Score, Median (range)35.7 (0.0-100)25.0 (0.0-75.0).002∗ Comparisons for these measures are not meaningful because they are used to define joint involvement. Abbreviations: ROM, range of motion; BSA, body surface area Open table in a new tab