Reliability, Validity, and Sensitivity to Change of the Cochin Hand Functional Disability Scale and Testing the New 6-Item Cochin Hand Functional Disability Scale in Systemic Sclerosis

Clinical trajectories of hand function impairment in systemic sclerosis: an unmet clinical need across disease subsets

BACKGROUND

Hand involvement is an early manifestation of systemic sclerosis (SSc), culprit of diagnosis and classification, and recognised major driver of disability. Impairment of hand function burdens both limited and diffuse cutaneous subsets and therefore could be targeted as 'basket' endpoint in SSc. Nevertheless, its natural history in current standard of care is not well characterised, limiting the design of targeted trials. The aim of this study is to describe prevalence, natural history and clinical factors associated with hand function deterioration in a longitudinal, multicentre, observational SSc cohort.

METHODS

Hand function was captured through the validated Cochin Hand Function Scale in patients consecutively enrolled in a multicentre observational study and observed over 24 months. Minimal clinically important differences and patient acceptable symptom state were analysed as previously described.

RESULTS

Three hundred and ninety-six consecutive patients were enrolled from 10 centres; 201 with complete follow-up data were included in the analysis. Median (IQR) disease duration was 5 (2-11) years. One hundred and five (52.2%) patients reported clinically significant worsening. Accordingly, the proportion of patients reporting unacceptable hand function increased over 2 years from 27.8% to 35.8% (p<0.001). Least absolute shrinkage and selection operator analysis identified male gender, disease subset, Raynaud's Condition Score, tenosynovitis and pain, as some of the key factors associated with worsening hand involvement.

CONCLUSIONS

Hand function deteriorates over time in more than 50% of SSc patients despite available therapies. The analysis of factors associated with hand function worsening supports the involvement of both inflammation, vascular and fibrotic processes in hand involvement, making it a hallmark clinical manifestation of SSc. Our data are poised to inform the design of intervention studies to target this major driver of disability in SSc.

Expanding the Treatment Team

The optimal systemic sclerosis (SSc) care plan includes an occupational therapist and physical therapist as well as wound care experts and a registered dietitian if indicated. Screening instruments for functional and work disability, hand and mouth limitations, malnutrition, and dietary intake can identify the need for ancillary support services. Telemedicine can assist in developing effective ancillary treatment plans. Reimbursement for services may limit access for patients with SSc to expand their care team but a focus on prevention rather than management of damage is recognized as an important unmet need in SSc. In this review, the role of a comprehensive care team for SSc is discussed.

Cultural adaptation, translation and validation of Cochin Hand Function Scale and evaluation of hand dysfunction in systemic sclerosis

OBJECTIVES

Hand dysfunction causes significant reduction in quality of life in systemic sclerosis. We assessed the validity and reliability of the culturally adapted Indian version of Cochin Hand Function Scale (I-CHFS). We determined the factors contributing to hand dysfunction and its burden on quality of life.

METHOD

I-CHFS was formulated by replacing five questions (questions 7, 9, 10, 14 and 15) in CHFS which were determined as unsuitable in an Indian setting. The instrument was assessed for acceptability, reliability, reproducibility and validity measures. A total of 87 patients were assessed for various demographic and disease parameters, hand disability and quality of life.

RESULTS

The median I-CHFS score was 22(5-54) and 04 (0.5-17.5) among diffuse (dcSSc) and limited cutaneous systemic sclerosis (lcSSc). I-CHFS showed good reproducibility (interclass correlation coefficient = 0.92) and a strong correlation with I-HAQ (r_s = 0.832), usual activities EQ-5D-5L (r_s = 0.744), self-care EQ-5D-5L (r_s = 0.734) and anxiety/depression EQ-5D-5L (r_s = 0.729). It had moderate correlation with pain/discomfort EQ-5D-5L (r_s = 0.661) and hand HAQ (r_s = 0.576) and poor correlation with HAQ-DI (r_s = 0.396) and modified Rodnan skin score (r_s = 0.390). Finger to table distance, finger to palm distance in extension and limited hand modified Rodnan skin score were significantly associated with higher values of I-CHFS.

CONCLUSIONS

Hand dysfunction in systemic sclerosis is substantial and contributes significantly to poor quality of life. The culturally adapted I-CHFS is a valid and reliable tool to assess it and correlated well with the overall disease burden. Key Points • Hand dysfunction is common among systemic sclerosis patients. • Hand dysfunction contributes to the poor quality of life and more disease burden. • Culturally adapted Cochin Hand function Scale helps assess hand dysfunction among Indian scleroderma patients.