What is the significance of the prayer sign in a patient with scleroderma?

Prayer Sign in Scleroderma

Clinical Significance and Definition

The prayer sign is a bedside test that detects limited joint mobility (LJM) of the hands in scleroderma patients and correlates with disease severity, particularly skin fibrosis extent. 1

The prayer sign test is performed by asking the patient to place their palms together in a prayer position with fingers extended—inability to fully approximate the palms and fingers indicates a positive test. 1

Diagnostic Value

Prevalence and Detection

• LJM detected by prayer sign is present in 66.4% of systemic sclerosis patients overall 1
• Diffuse cutaneous SSc (dcSSc) patients show significantly higher rates of positive prayer signs compared to limited cutaneous SSc (lcSSc) patients 1
• The prayer sign demonstrates moderate correlation with the modified Rodnan skin score (mRss), which is the validated measure of skin thickness in scleroderma (lcSSc r=0.449; dcSSc r=0.565) 1

Prognostic Implications

• LJM staging using the prayer sign correlates with disease severity and can serve as a prognostic indicator for early-stage SSc patients 1
• Patients with dcSSc demonstrate more severe LJM findings than those with lcSSc, reflecting the more aggressive nature of diffuse disease 1

Complementary Assessment: Tabletop Sign

The tabletop sign is performed alongside the prayer sign—the patient attempts to place their palm flat on a table surface, with inability to do so indicating positive LJM. 1

Both tests together provide a simple, reproducible bedside assessment that mirrors the clinical information obtained from the more time-intensive mRss. 1

Clinical Context in Scleroderma

Disease Classification Relevance

• Diffuse cutaneous SSc involves skin fibrosis both distal and proximal to elbows/knees and trunk, while limited cutaneous SSc affects only distal extremities 2, 3
• The extent of skin involvement determines disease phenotype and correlates with internal organ complications 4

Associated Musculoskeletal Findings

• Inflammatory arthritis occurs in approximately 15% of SSc patients 3
• Myositis or myopathy affects about 15% of patients 3
• Tendon friction rubs may indicate more aggressive disease 3

Practical Application

The prayer sign and tabletop sign should be incorporated into routine clinical assessment of all scleroderma patients as simple, no-cost screening tools that provide immediate information about disease severity and progression. 1

These tests are particularly valuable for:

• Monitoring disease progression over time in established patients 1
• Early detection of worsening skin involvement 1
• Identifying patients who may require more aggressive systemic therapy 1

Important Caveats

• While the prayer sign correlates with skin score, it does not directly predict specific internal organ involvement such as interstitial lung disease or pulmonary arterial hypertension, which require dedicated screening protocols 4, 2
• A positive prayer sign should prompt comprehensive organ-based screening according to EULAR and ACR guidelines, including pulmonary function testing, high-resolution CT when indicated, and echocardiography 2
• The prayer sign reflects hand involvement specifically and should not be used in isolation to assess overall disease activity or guide treatment decisions 1