Swelling
Bony overgrowth, fibrosis and/or isolated bursitis should NOT be classified as swelling (but should be noted in the comments section). Bony overgrowth and fibrosis are distinctly more firm than puffy swelling.
It should be noted that bony overgrowth and swelling may both be present at the same time, with swelling being visible and/or palpable. The swelling should be scored as per the instruction manual & the bony deformity noted in the comment section on the worksheet.
Do not score edema (for example, related to tissue) as swelling. Look for swelling focused on the joint itself. Make note of findings in the comment section on the worksheet.
Muscle Atrophy
To discriminate between muscle atrophy and muscle asymmetry related to motor dominance one should take into account that a muscle loses its normal anatomical shape in a pathophysiological condition such as in joint disease and maintains its physiological contour in a condition of motor dominance. So, if the muscle on a non-dominant limb has maintained its normal contour even though it appears slightly smaller, the score for muscle atrophy would be “0”.
Strength
In the majority of cases, there may actually be a little motion present. If this is the case, then do a standardized muscle test as you would for a joint that had more motion. However, if the joint is truly fused, and there is no functional motion, you should record it as “NE” (Non-evaluable) on both the Worksheet and Summary Score Sheet, and give the reason why it is being scored “NE”. See the guidelines in the HJHS Instruction Manual for using “NE” (Addendum Section).
If a patient is unable to at least clear their heel off of the floor in standing (when assessing ankle plantarflexion strength), you would test them in prone or supine. If they can give good resistance with a break test in this position, they would get a muscle grade of 2+ and an HJHS score of 3. See the HJHS Instruction Manual, Section 6 Strength (pg 11, 19 & 20).
Range of Motion
In some cases there may actually still be a little motion present. In this situation, measure & record the available ranges of flexion and extension. Then, determine the score for flexion loss and extension loss using both the Comparative side and Normative range tables.
If the joint is completely fused, record the measurement. For example: the ankle is fused in 5⁰ of plantarflexion. Record Plantarflexion as: 5⁰. Record Dorsiflexion as: -5⁰. Determine the scores for Flexion loss and Extension loss according to the guidelines using both the Comparative side and Normative range tables.
The HJHS assesses the talo-crural joint which is responsible for dorsiflexion and plantarflexion. As patients begin to lose motion in this joint, they can become quite adept at compensating by using mid-foot and forefoot motion to compensate for what they have lost at the talo-crural joint. This can be seen in both dorsiflexion and plantarflexion, but it is most evident with plantarflexion. Because our age-matched normal ranges were established by aligning the goniometer arm parallel to the 5th metatarsal, it is necessary to measure your patients using this same landmark. However, document clinically relevant observations e.g. patient/subject uses forefoot compensation in the comment section of the worksheet for comparison with later observations.
General
When it is necessary to use the NE option, usually the total score denominator will not change. The exception to this would be with a child who developmentally is unable to perform the skill. The maximum score for that item would be subtracted from the total HJHS score and adjusted for in the analysis. For instance, if a child cannot hop on 1 leg due to developmental immaturity, NE would be recorded for global gait. Since 4 is the maximum score for global gait, the new denominator for the total HJHS score would be 120 rather than 124.
When the HJHS is administered, the Non-evaluable (NE) item should be used as little as possible. If it is used due to perceived or real risk of bleeding or injury, the total score denominator of 124 would not change.
In the case of an amputation, that is where there is no (e.g. ankle) joint, all items for that joint would be scored “NE”. The total score for that joint (20) would be subtracted from the HJHS total score denominator and the new denominator would be 104 (provided that gait could still be assessed).
Yes! Although some of the HJHS item scores may change post-joint replacement (e.g., crepitus), you can still assess the joint to track the joint health over time.
The HJHS co-developers suggest that if a research study includes a patient who had a joint replacement at least 6 months prior to study initiation (i.e. the joint has stabilized), the joint score can be included in the total joint score. If a joint is replaced just prior to or during the study, it may lead to a changing score over the period of the study that does not relate to the study intervention. In this situation, the involved joint score may not be included for the full study period.
The surgery type, joint & date should be noted in the comments section on the HJHS worksheets & Summary Score sheet.
Non-Evaluable Scoring
Please refer to the file below for detailed information regarding the scoring of Non-Evaluable items.
Learn more
If you have any questions regarding the administration and use of the Hemophilia Joint Health Score please contact our Help Desk hjhs.helpdesk@sickkids.ca