Graft-versus-host disease (GVHD) can affect multiple organs including joints, skin, fascia, and ligaments , which can have a major impact on patient’s quality of life in patients who underwent hematopoietic cell transplantation (HCT) . From the current literature, it is well established that patients suffering from musculoskeletal (MSK) GVHD can present with a wide range of symptoms like fasciitis in the hands resulting in dysfunction of the long finger flexors and extensors along with edema of hands , avascular necrosis of the hips , and polymyositis causing proximal muscle weakness in the hips and the shoulders . Unless these patients are assessed, and the MSK manifestations identified at an early stage, these patients remain at risk of developing contractures, muscle loss, loss of function eventually resulting in reduced range of motion (ROM), and delay in functional recovery. Furthermore, patients who receive cytotoxic chemotherapy and corticosteroids (e.g., for leukemias) pre-HCT, are known to have reduced functional performance, which means that post transplant, MSK functional assessments in the absence of pre-HCT functional values can be misleading at times as it would be difficult to establish the norm of the particular patient.
We would like to illustrate the importance of obtaining full-body functional assessment pre-transplant and post transplant based on cases presented in Table 1 and we would also like to put forward a proposal for developing a modified MSK GVHD (originally based on the 2014 National Institutes of Health Chronic GVHD consensus criteria) functional grading system specific for rehabilitation team (Table 2). We present following three allogeneic HCT cases to support our argument: case A was a 14-year-old female with sickle cell disease, the case B was a 23-year-old male with myelodysplastic syndrome, and case C was a 15-year-old male with B-cell acute lymphoblastic leukemia.
Cases A and B were referred post transplant to PT for chronic graft-versus-host disease (cGVHD) management of ankles and wrists respectively. However, interestingly, although cases A and B were referred for specific joint area management, their full-body assessments revealed multiple joint involvements in relation to their ROM, function, and strength. Moreover, in both cases, the aim of the patient for rehabilitation was very different to that for which they were referred by the physician. The case A’s main concern was not the ROM in the ankles, but was about the gait and her ability to walk normally (Fig. 1); for case B, his main concern was not wrists or shoulder decreased ROM of the joints, but his inability to sit on the floor due to tight hip flexor and quadriceps bilaterally (Fig. 2). Furthermore, we also discovered a pattern of abnormal ROMs during the functional assessments, e.g., in case B, a significant difference in ROM was seen when measurement was carried out for wrist extension with fingers closed to that compared to fingers open, thus indicating the complex myofascial chain involvement (Fig. 3 and Fig. 4).
Case C was referred pre-HCT and we carried out a full-body functional assessment that included upper and lower limb ROM testing, strength, and functional ability testing. On evaluation, we found this patient to have significantly weak grip and pinch strength, tight hamstrings, reduced ankle ROM, and generalized reduced muscle strength in upper and lower limb.
The full-body functional assessment pre- and post-HCT and for cGVHD patients is not only helpful for early identification of MSK-related problems, but can also act a precursor in providing timely intervention. An MSK rehabilitation-specific modified assessment can be developed by closely studying various patterns of myofascial and joint involvement in cGVHD patients, combined with functional evaluations.
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J.M., A.A., and S.K.H. wrote the manuscript. All authors contributed substantially to the conception, acquisition, analysis, and interpretation of the data for the work.
Conflict of interest
The authors declare that they have no conflict of interest.
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Mohammed, J., AlGhamdi, A. & Hashmi, S.K. Full-body physical therapy evaluation for pre- and post-hematopoietic cell transplant patients and the need for a modified rehabilitation musculoskeletal specific grading system for chronic graft-versus-host disease. Bone Marrow Transplant 53, 625–627 (2018) doi:10.1038/s41409-017-0075-3
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