1
|
Benemei S, Mattia C, Di Minno MND. The good, the bad and the ugly of pain in haemophilia: Recent evidence on the epidemiology, molecular mechanisms and knowledge gaps preventing optimal treatment. Haemophilia 2024; 30:589-597. [PMID: 38545868 DOI: 10.1111/hae.15002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/16/2024] [Accepted: 03/03/2024] [Indexed: 05/15/2024]
Abstract
INTRODUCTION Haemophilia is an inherited, X-linked blood clotting disorder caused by the deficiency of coagulation factors VIII (FVIII, haemophilia A) or IX (FIX, haemophilia B). Spontaneous bleeds are common in severe forms of haemophilia and can also occur in moderate and mild haemophilia. Severe or repeated bleeding at a joint can evolve into chronic haemophilic arthropathy, with functional damage of the joint, disability, and intense chronic articular pain. Nonetheless, acute and chronic pain may emerge due to secondary conditions related to bleedings. AIM This narrative review aims to critically discuss the most recent evidence about pain in haemophilia to give healthcare professionals a clear picture of current knowledge hence favouring the optimisation of clinical management of pain. METHODS Extensive literature search with the terms 'hemophilia' AND 'pain', focusing on the time window 2021-2023. RESULTS Acute and chronic pain is a critical aspect of haemophilia at all ages. It should be considered a multifaceted phenomenon, with a positive role as an early emergency signal of a clinical event (haemarthrosis), and numerous detrimental aspects linked to its burden that heavily affects the health-related quality of life, with psychological and social consequences. CONCLUSION Despite its prevalence and frequency in people with haemophilia, pain is often underestimated by healthcare professionals, leading to insufficient and inadequate treatment, also due to uncertainty linked to the presence of the coagulation disorder or arthritic flares.
Collapse
Affiliation(s)
| | - Consalvo Mattia
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Faculty of Pharmacy and Medicine, 'ICOT-Polo Pontino, Sapienza' University of Rome, Rome, Italy
| | | |
Collapse
|
2
|
Ransmann P, Tomschi F, Schmidt A, Brühl M, Hilberg T. Paradox pain sensitivity using cuff pressure or algometer testing in patients with hemophilia. Scand J Pain 2024; 24:sjpain-2023-0128. [PMID: 38592740 DOI: 10.1515/sjpain-2023-0128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/20/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Pain is a common comorbidity in patients with hemophilia (PwH) due to hemophilic arthropathy. This study aims to explore pain sensitivity in PwH methodologically investigating in cuff pressure testing compared to algometer testing. METHODS 37 PwH and 35 healthy control subjects (Con) enrolled in this study. Joint health status was assessed. Subjective pain was evaluated using numeric rating scales. Pain sensitivity was measured with pressure algometry and cuff pressure algometry. Pressure pain thresholds of the algometer (PPTa) were measured at knee, ankle joints, and forehead. Subsequently, thresholds of cuff pressure were measured at the left and right lower legs (PPTcuff). In both, lower values represent higher pain sensitivity. RESULTS PwH exerted a worse joint health status than Con. Pain sensitivity was higher in PwH compared to Con as PPTa of the knee and ankle joints were lower in PwH. No difference was observed in PPTa at the forehead. Contrastingly, lower pain sensitivity was detected in PwH by higher PPTcuff values compared to Con in both legs. CONCLUSION While PPTa of the knee and ankle joints are lower in PwH, PPTcuff are higher in PwH compared to Con. This reveals a paradox situation, highlighting that PwH experience local, joint- and hemophilic arthropathy-related pain, whereas pain sensitivity of non-affected soft tissue structures is lower. The reasons explaining the PPTcuff results remain elusive but might be explained by coping strategies counteracting chronic joint pain, resulting in lower sensitivity at non-affected structures.
Collapse
Affiliation(s)
- Pia Ransmann
- Department of Sports Medicine, University of Wuppertal, Moritzstraße 14, 42117, Wuppertal, Germany
| | - Fabian Tomschi
- Department of Sports Medicine, University of Wuppertal, Moritzstraße 14, 42117, Wuppertal, Germany
| | - Alexander Schmidt
- Department of Sports Medicine, University of Wuppertal, Moritzstraße 14, 42117, Wuppertal, Germany
| | - Marius Brühl
- Department of Sports Medicine, University of Wuppertal, Moritzstraße 14, 42117, Wuppertal, Germany
| | - Thomas Hilberg
- Department of Sports Medicine, University of Wuppertal, Moritzstraße 14, 42117, Wuppertal, Germany
| |
Collapse
|
3
|
Kubeš R, Stollin M, Magersky Š, Bobelyak M, Vaculík J, Včelák J, Antonín Kuběna A, Loužil J, Salaj P. Predicting the development of hemophilic arthropathy in patients with hemophilia based on patient age: a retrospective single-center database study. Expert Rev Hematol 2023; 16:1099-1105. [PMID: 38015035 DOI: 10.1080/17474086.2023.2289536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Patients with hemophilia (PWH) develop hemophilic arthropathy of the major joints due to recurrent hemarthrosis. This study retrospectively estimated the age at which PWH may expect to develop hemophilic arthropathy and undergo joint replacement surgery. RESEARCH DESIGN AND METHODS Using retrospective data from PWH at a Czech orthopedic center, Kaplan Meier analyses were used to estimate the cumulative proportions of patients with hemophilic arthropathy and undergoing joint replacement surgery as a function of age. RESULTS Based on 1028 joint examinations in 167 PWH, hemophilic arthropathy of the knees, elbows, ankles and hips was estimated to develop by a median age of 48, 51, 52 and 61 years, respectively, with ≈80% of patients having such damage by ≈70 years of age. Hemophilic arthropathy of the shoulder occurred much later (median >80 years). In patients undergoing knee or hip replacement surgery, hemophilic arthropathy of the knee and hip occurred at a median age of ≈50 and ≈60 years, respectively, with replacement surgery occurring at a median of ≈70 and >75 years. CONCLUSIONS In PWH, the risk of developing hemophilic arthropathy accumulates continuously over the patient's lifetime, allowing predictions about the ages at which such damage and joint replacement surgery may occur.
Collapse
Affiliation(s)
- Radovan Kubeš
- Department of Orthopaedics, First Faculty of Medicine, Charles University, Prague 8, Czech Republic
- Orthopedic Clinic, First Faculty of Medicine Charles University and Institute for Postgraduate Education in Medicine, Prague 8, Czech Republic
| | - Martin Stollin
- Department of Orthopaedics, First Faculty of Medicine, Charles University, Prague 8, Czech Republic
- Orthopedic Clinic, First Faculty of Medicine Charles University and Institute for Postgraduate Education in Medicine, Prague 8, Czech Republic
| | - Štěpán Magersky
- Department of Orthopaedics, First Faculty of Medicine, Charles University, Prague 8, Czech Republic
- Orthopedic Clinic, First Faculty of Medicine Charles University and Institute for Postgraduate Education in Medicine, Prague 8, Czech Republic
| | - Maryan Bobelyak
- Department of Orthopaedics, First Faculty of Medicine, Charles University, Prague 8, Czech Republic
- Orthopedic Clinic, First Faculty of Medicine Charles University and Institute for Postgraduate Education in Medicine, Prague 8, Czech Republic
| | - Jan Vaculík
- Department of Orthopaedics, First Faculty of Medicine, Charles University, Prague 8, Czech Republic
- Orthopedic Clinic, First Faculty of Medicine Charles University and Institute for Postgraduate Education in Medicine, Prague 8, Czech Republic
| | - Josef Včelák
- Department of Orthopaedics, First Faculty of Medicine, Charles University, Prague 8, Czech Republic
- Orthopedic Clinic, First Faculty of Medicine Charles University and Institute for Postgraduate Education in Medicine, Prague 8, Czech Republic
| | - Aleš Antonín Kuběna
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy, Charles University, Hradec Králové, Czech Republic
| | - Jan Loužil
- Transfusiological Division, Institute of Hematology and Blood Transfusion, Prague 2, Czech Republic
| | - Peter Salaj
- Centre for Thrombosis and Hemostasis, Institute of Hematology and Blood Transfusion, Prague 2, Czech Republic
| |
Collapse
|
4
|
Cuesta-Barriuso R, Donoso-Úbeda E, Meroño-Gallut J, Ucero-Lozano R, Pérez-Llanes R. Hemophilic Arthropathy: Barriers to Early Diagnosis and Management. J Blood Med 2022; 13:589-601. [PMID: 36277171 PMCID: PMC9586168 DOI: 10.2147/jbm.s343924] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
Abstract
Hemophilia is a congenital coagulopathy characterized by a deficiency of one of the clotting factors. It is characterized by the development of hematomas and hemarthrosis, either spontaneously or after minor trauma. The recurrence of hemarthroses leads to progressive and degenerative joint damage from childhood (hemophilic arthropathy). This arthropathy is characterized by disabling physical effects that limit the functionality and quality of life of these patients. Medical progress achieved over the last decade in the drug treatment of hemophilia has improved the medium and long-term prospects of patients with more effective and long-lasting drugs. The universal use of safer, more effective and prolonged prophylactic treatments may promote the prevention of bleeding, and also therefore, of the development of hemarthrosis and joint damage. A number of imaging instruments have been developed for the assessment of hemarthrosis and hemophilic arthropathy, using ultrasound, magnetic resonance imaging and simple radiology. Different physical examination scores and questionnaires allow the assessment of joint health, self-perceived activity and functionality of patients with hemophilia. The approach to these patients should be interdisciplinary. Assessment of the processes that affect pain in these patients and the development of pain education models should be implemented. Expert advice and information to patients with hemophilia should be based on individual functional prevention diagnoses, advice on available therapies and sports practice, as well as health recommendations.
Collapse
Affiliation(s)
- Rubén Cuesta-Barriuso
- Department of Surgery and Medical-Surgical Specialties, University of Oviedo, Oviedo, Spain,Royal Victoria Eugenia Foundation, Madrid, Spain,Correspondence: Rubén Cuesta-Barriuso, Department of Surgery and Medical-Surgical Specialties, University of Oviedo, Campus de El Cristo s/n, Faculty of Medicine, Oviedo, 33006, Spain, Tel +34 985 103 386, Email
| | - Elena Donoso-Úbeda
- Department of Physiotherapy, Catholic University San Antonio-UCAM, Murcia, Spain
| | | | | | - Raúl Pérez-Llanes
- Department of Physiotherapy, Catholic University San Antonio-UCAM, Murcia, Spain
| |
Collapse
|
5
|
The Application of Focused Medium-Energy Extracorporeal Shockwave Therapy in Hemophilic A Arthropathy. Healthcare (Basel) 2022; 10:healthcare10020352. [PMID: 35206968 PMCID: PMC8871785 DOI: 10.3390/healthcare10020352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/01/2022] [Accepted: 02/08/2022] [Indexed: 12/04/2022] Open
Abstract
Hemophilic arthropathy causes the damage of synovium, cartilage, and subchondral bone. The present study evaluated the safety and the effect of extracorporeal shockwave therapy (ESWT), a safe treatment widely used in musculoskeletal conditions in patients with hemophilic arthropathy. Between 1 August 2019 and 31 July 2020, seven hemophilia A patients were enrolled and treated with medium-energy ESWT on the knee joint in the first two months after prophylactic coagulation factor administration. At the beginning of the study and at 1-, 2-, 3-, and 6-month follow-ups, the Hemophilia Joint Health Score (HJHS), visual analog scale score (VAS), and Hemophilia Early Arthropathy Detection with Ultrasound score (HEAD-US) were evaluated for therapeutic effectiveness and safety, while serum bone morphogenetic protein 2 (BMP-2) and von Willebrand factor (vWF) levels were analyzed for assessing chondroprotection and bone healing. Magnetic resonance imaging (MRI) of the knee was performed at the beginning of the study and the 6-month follow-ups. As a result, a non-significant decrease in VAS scores (p = 0.151) but not HJHS after treatment was noticed. At the 3-month follow-up, there was a non-significant increase in BMP2 levels (p = 0.171) but not vWF. Ultrasonography showed no disease activity score elevation in five patients and no further disease damage in all patients. Repeated MRI examinations in three patients showed no structural progression during the 6-month follow-up. As to adverse events, redness, local heat, and mild swelling were noted in five patients without breakthrough bleeding. We concluded that medium-energy ESWT might be safe for hemophilic arthropathy once prophylactic coagulation factors are administered.
Collapse
|