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chronic graft versus host disease ( cgvhd ) belongs to the most serious and frequent ( 3070% ) complications in patients undergoing hemopoietic stem cells transplantation ( hsct ) for hematological malignancies .
musculoskeletal and skin cgvhd , by inducing fibrotic changes in tissues , may result in reduction of joints range of motion ( rom ) , loss of muscular strength and , finally , in functional impairment , compromising the activities of daily living ( adl ) .
supportive cares , such as physical rehabilitation and occupational therapy , although recommended as ancillary therapy , have been rarely experienced in such a condition .
, recently presented , dealt with a single case of motor rehabilitation in a patient with cgvhd - related contractures . at the best of our knowledge , it represents the first reported case of extensive cgvhd with skin and musculoskeletal involvement treated with physical rehabilitation in an adult patient .
thereby , we described an additional case of a patient with similar cgvhd involvement recently treated with physical rehabilitation within our homecare program .
a 39-year - old man affected by chronic myeloid leukemia ( cml ) in third relapse after allogeneic hsct and not eligible for further active therapy was referred to our homecare service as advanced / terminal patient in june 2008 . at diagnosis , in 1992 ,
he had been submitted to hla identical sibling allogeneic hsct , obtaining complete remission ( cr ) ; in 1998 , a disease relapse , as accelerate phase of cml , occurred .
therefore , a second hla identical sibling allogeneic hsct , from a different donor , was performed and both hematological and cytogenetic remission were achieved . in 2004 ,
the patient developed a second hematological relapse ( myeloid blast crisis ) and he was given donor lymphocyte infusions ( dli ) and imatinib ; after three dlis at escalating doses , a molecular cr was obtained .
however , 8 months later , he developed extensive cgvhd ( skin , mouth , eye ) and , therefore , immunosuppressive therapy ( steroids and extracorporeal photoferesis ) was started , without improvement , such that cgvhd progressed with the addition of lung involvement .
therefore , the patient received multiple lines of immunosuppressive drugs ( rituximab , cyclosporine , plaquenil and mycophenolate ) with only a poor response . meanwhile , in june 2007 , he developed a third relapse ( extramedullary lung and bone involvement ) and was treated with imatinib and dasatinib without response and therefore he was considered not eligible for further causal therapy . at admission in the homecare service , the patient presented with an extensive skin and musculoskeletal cgvhd ; barthel index ( bi ) , as adl measure , was 40 ( moderate  severe reduction ; normal = 100 ) , as a result of diffuse contractures with severe reduction of joints rom [ table 1 ] ; secondary , legs muscles hypotrophy was increased due to spinal cord disease - related compression .
the patient was assisted with a fully homecare program , with medical and nursing periodic examination , transfusions support and motor rehabilitation .
both physical and occupational therapy were promptly started , with particular attention to stretching exercises for joints ; planned intensity was 3 sessions per week .
after 4 weeks of treatment , planned intensity was respected and no rehabilitation - related complications were noted .
although bi did not improve , the rom of treated joints increased and the mean rom improvement ( expressed as percentage of baseline value ) was 52.5% [ table 1 ] ; both motor skills , psychological aspects and patient quality of life had significant amelioration .
after 5 weeks , rehabilitation was discontinued because of infectious pneumonia and , 1 month later , an attempt to restart failed due to rapid deterioration . in november 2008 ,
range of motion in major joints : normal value , baseline value ( t0 ) , after 1 month of treatment ( t1 ) and improvement expressed as percentage of baseline value (  )
musculoskeletal involvement , in the course of cgvhd , is a rare phenomenon ; larger reported series describe cgvhd - related fasciitis or myositis in less than 1% of the patients undergoing allogeneic sct .
musculoskeletal cgvhd , expression of an immunological response toward recipient antigens , is considered an organ involvement in the course of a widespread disease , and systemic immunosuppressive therapy is the standard approach of treatment .
however , local treatment should be used in order to improve response and to reduce toxicity , allowing a prompt and rapid escalation of systemic treatment .
although data derived from experiences in different immunologically mediated musculoskeletal contractures suggest an important role of physical rehabilitation , such a therapy remains a poorly explored issue in patients with cgvhd , with few data reported in adult patients .
although limited , confirm the possibility of almost temporary results , also in long - lasting cgvhd - related contractures .
monitoring for musculoskeletal involvement in patients at risk for or with initial features of cgvhd is required , both to prospectively evaluate cgvhd - related muscoloskeletal involvement and to enroll patients at an initial disease stage .
clinical trials have to be developed to adequately assess feasibility , safety and efficacy of motor rehabilitation in response to the need to prevent disease progression toward rom limitation and consequent disability .
chronic graft versus host disease ( cgvhd ) is a frequent complication of allogeneic stem cell transplantation . 
 extensive musculoskeletal and skin involvement may induce severe functional impairment , disability and quality of life deterioration . 
 physical rehabilitation is recommended as ancillary therapy in these forms , but experiences are sparse . 
 a 39-year - old man affected by musculoskeletal and skin chronic graft versus host disease ( cgvhd ) was treated with a homecare - based motor rehabilitation program during palliation for disease progression . 
 significant functional improvement was obtained . 
 motor rehabilitation should be strongly considered for patients with musculoskeletal cgvhd , both in the palliative and in the curative phase of disease .