359 Malcarne,etal:QualityoflifeinSSc Personal non-commercial use only. The Journal of Rheumatology Copyright © 2007. All rights reserved. Medical Signs and Symptoms Associated with Disability, Pain, and Psychosocial Adjustment in Systemic Sclerosis VANESSAL. MALCARNE, INGUNN HANSDOTTIR,ANN McKINNEY, RENN UPCHURCH, HELEN L. GREENBERGS, GRETCHEN H. HENSTORF, DANIEL E. FURST, PHILIP J. CLEMENTS, and MICHAEL H. WEISMAN ABSTRACT. Objective. Toexaminephysician-assessedmedicalsignsandpatient-reportedmedicalsymptomsascor- relates of 3 quality of life (QOL) outcomes in patients with systemic sclerosis (SSc): disability, pain, and psychosocial adjustment. Methods. One hundred fourteen patients with SSc underwent a comprehensive clinical examination including determination of skin thickening [Modified Rodnan Skin Score (MRSS)]. Patients reported current symptoms and completed standardized questionnaires assessing disability and pain (Health Assessment Questionnaire) and psychosocial adjustment (Psychosocial Adjustment to Illness Scale). Regression analysis was used to examine physician-determined and patient-reported correlates of the 3 outcomes. Results. MRSS was a significant correlate of all outcomes, although it explained only a small amount ofthevarianceinpsychosocialadjustment.Patient-reportedpostprandialbloatingwasthestrongestcor- relate of psychosocial adjustment, explaining more than twice as much variance as MRSS. After accountingforMRSS,patient-reporteddependentedemasignificantlycorrelatedwithalloutcomes.For disability, significant correlates were physician-determined joint tenderness and number of tender points, and patient-reported joint pain on motion, joint contracture, extremity ulcers other than digital, anddyspnea.Patient-reportedjointtendernesswassignificantlyassociatedwithpain.Regressionanaly- sis supported a model in which disability and pain mediated the relationship between MRSS and psy- chosocial adjustment. Conclusion. Skin score is strongly associated with disability and pain, but only weakly associated with psychosocial adjustment. Dependent edema has negative implications across quality-of-life outcomes. Disability and pain mediate the relationship between disease severity and psychosocial adjustment to disease. Assessment (including self-report of patient symptoms) of specific medical signs and symp- toms may indicate SSc patients experiencing diminished QOL. (J Rheumatol 2007;34:359–67) KeyIndexingTerms: SCLERODERMA QUALITYOF LIFE PSYCHOSOCIALADAPTATION DISABILITY PAIN FromtheDepartmentofPsychology,SanDiegoStateUniversity; SDSU/UCSDJointDoctoralPrograminClinicalPsychology,SanDiego; DivisionofRheumatology,DavidGeffenSchoolofMedicine,UCLA,Los Angeles;DivisionofRheumatology,Cedars-SinaiMedicalCenter,Los Angeles,California;andVirginiaMasonMedicalCenter,Seattle, Washington,USA. Supportedinpartbythegrant“PsychosocialandMedicalAspectsof Scleroderma”fromtheNationalInstitutesofArthritisand MusculoskeletalandSkinDiseases(5P60AR40770-04). V.L.Malcarne,PhD,Professor;I.Hansdottir,PhD,Research Psychologist;A.McKinney,MA,ResearchAssociate;R.Upchurch,MA, DoctoralCandidate;H.L.Greenbergs,PhD,PostdoctoralFellow; G.H.Henstorf,BA,ResearchAssociate;D.E.Furst,MD,Professorof Medicine;P.J.Clements,MD,ProfessorofMedicine;M.H.Weisman,MD, ProfessorofMedicine. AddressreprintrequeststoDr.V.L.Malcarne,SDSU/UCSDJoint DoctoralPrograminClinicalPsychology,6363AlvaradoCourt,Suite 103,SanDiego,CA92120-4913.E-mail:malcarne@psychology.sdsu.edu AcceptedforpublicationSeptember29,2006. Systemic sclerosis (SSc) is chronic, progressive, and debili- tating, but until recently few studies have examined what spe- cific features of the disease have the greatest influence on health-related quality of life (QOL), or which patients are at greatest risk for poor QOL outcomes 1,2 . QOL outcomes par- ticularly relevant to SSc include disability, pain, and psy- chosocial adjustment. Disability has received the most sys- tematic study. Most studies have used the self-report Health Assessment Questionnaire (HAQ) 3 or the scleroderma-modi- fied HAQ (SHAQ) 4 , both of which yield a Disability Index (HAQ-DI) that has been validated for SSc 4-13 . Generally, patientswithdiffusecutaneousSSc(dcSSc)reportgreaterdis- ability than patients with limited cutaneous SSc (lcSSc), and more skin thickening (assessed by skin score) is associated with greater disability 4,5,11,14-17 , although a recent French study did not find these relationships 18 . Considering more specific clinical signs, HAQ-DI has been shown to be related to joint pain, swelling, and/or tenderness 4,5,7,8 , proximal mus- cle weakness 5 , loss of hand mobility 5,11 , presence of tendon friction rubs 5 , and heart/kidney involvement 4 . Two recent studies have found digital ulcers are related to higher disabil- ity 10,11 , although an earlier study did not find this relation- www.jrheum.org Downloaded on April 16, 2022 from