Pain in haemophilia: are we listening?

Prevalence and Interference of Chronic Pain Among People With Hemophilia: A Systematic Review and Meta-Analysis

Chronic pain is a common condition among people with hemophilia (PWH), associated with joint deterioration due to repeated joint bleeds. This systematic review and meta-analysis aimed to determine the prevalence of chronic pain due to haemophilia and to analyze its interference in the lives of patients. A systematic search was performed in May and June 2019 and updated in February 2021, using PubMed, EMBASE, Web of Science and SciElo. The search included terms related to hemophilia, pain, pain prevalence and pain interference. Studies were included if they reported data referring to hemophilia-related chronic pain among adult males (age ≥18). From 3,258 identified studies, 11 met the inclusion criteria. Three studies used a proposed definition for hemophilia-related chronic pain and 8 used direct questions developed by the authors. For the global samples, prevalence ranged from 17% to 84%. The random-effects meta-analysis including all studies demonstrated a pooled prevalence of chronic pain of 46% (95% Confidence Interval, CI = 34%-58%). Subgroup analysis of samples including all disease severities or including only severe patients revealed a pooled prevalence of 48% (95% CI = 29%-67%) and 53% (95% CI = 38%-69%), respectively. High heterogeneity between studies was observed in all models. Information concerning chronic pain interference was retrieved from 1 study, reporting a mean interference of 3.7 (0-10 numerical rating scale from the Brief Pain Inventory). This systematic review revealed a wide prevalence range of hemophilia-related chronic pain across studies, varying methodologies and sample characteristics. Research in the hemophilia field should clearly distinguish between acute and chronic pain and provide complete characterization of study samples. PERSPECTIVE: Pain is a central issue in the lives of people with hemophilia, posing a significant challenge for healthcare providers. A clear picture of chronic pain due to hemophilia is precluded by high heterogeneity among studies and various definitions used to investigate its prevalence.

Improving assessment and management of pain in hemophilia: an Italian Delphi consensus statement

Comprehensive evidence-based guidelines and well-validated assessment scales for pain in people with hemophilia (PwH) are needed. Here, we report 28 statements covering five topics on pain assessment and management in pediatric and adult PwH that were developed by 60 Italian hemophilia specialists during a Delphi consensus process. Overall, a clear consensus was achieved for 19 of the 28 statements. Consensus was reached on all statements on the topic of pain assessment and quality of life (QoL), including the need for regular pain assessment on a quantitative scale, the importance of distinguishing between different pain types, and the need to evaluate the impact of pain on patient QoL. The other four topics concerned acute and chronic pain management in adults and in children. Consensus was reached on statements regarding non-pharmacologic treatment and the use of first-line paracetamol (acetaminophen). There was a lack of consensus regarding the use of non-steroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, or opioids.

The effectiveness of cognitive-behavioural therapy on emotional regulation and quality of life in children with Haemophilia

AND BACKGROUND DATA

Haemophilia has known as an inherited bleeding disorder accompanied by remarkable pain, emotional distress, and impaired quality of life (QoL) and emotional regulation. Psychological interventions, such as cognitive-behavioural therapy (CBT), have cost-effectiveness to promote emotional well-being, QoL and emotional regulation; however, they have been scarcely used in the treatment of haemophilia.

OBJECTIVES OF THE STUDY

This research aimed at examining the effect of CBT on emotional regulation and QoL in children with haemophilia using quasi-experimental research with pretest and post-test design and a control group.

METHOD

30 subjects were selected using convenient sampling and divided into two groups (n = 15). Both groups responded to the QoL questionnaire, the Persian version of the Pediatric Quality of Life Inventory (PedsQL) developed and the Cognitive Emotion Regulation Questionnaire (CERQ-k) in the pretest. The experimental group was then subjected to the CBT intervention through 9 sessions. The analysis of covariance was used for data analysis.

RESULTS

There was a significant increase in the QoL and emotion regulation in the experimental group than the control group.

CONCLUSION

The CBT training was effective to stop negative thinking and control their anger at school and also to adopt more appropriate strategies to deal efficaciously with concerns in social situations. Awareness about the thoughts, feelings and behaviours and being able to solve problems enables children to have better social relations and friendships with peers and also in other social situations. It also can increase the QoL and emotion regulation.

Chronic pain in patients with hemophilia: is it preventable?

: Current management of chronic pain in patients with hemophilia (PWH) focuses on pain relief with analgesics and symptom control. The clinical practice of managing chronic pain in PWH varies considerably across hemophilia treatment centers. Here, we aim to study the appropriate intervention of hemophilic arthropathy for prevention and treatment of chronic pain in PWH. Medline, Embase, Cochrane databases were searched for randomized controlled trials, and the European Hemophilia Therapy Standardization Board, The World Federation of Hemophilia, Nordic Hemophilia Guidelines, American Society of the International Pain Physicians and the Medical and Scientific Advisory Council guidelines were studied through November 2019 for chronic pain in PWH for a narrative review. We found no standardized approach for the prevention and management of chronic pain in PWH. Evidence suggests that prophylactic factor concentrate therapy, programmed exercise and educational intervention may help PWH manage their chronic pain.

Pain Prevalence, Characteristics, and Impact Among People with Hemophilia: Findings from the First Portuguese Survey and Implications for Pain Management

Background

Hemophilia is a rare disorder characterized by spontaneous bleeding, with pain being a critical aspect. However, a systematic assessment of hemophilia-related pain in Portugal has never been conducted.

Objective

To understand the pain experience among Portuguese people with hemophilia (PWH) by describing its prevalence, characteristics, and impact and uncovering intervention needs in the realm of hemophilia-related pain care.

Methods

A cross-sectional observational survey, with age-adapted versions of questions concerning pain, emotional distress, and quality of life, was answered by 104 adults, 21 children/teenagers (10–17 years), and 19 children (1–9 years).

Results

Pain was reported by 82 (78.8%) adults, 16 (76.2%) children/teenagers, and 13 (68.4%) children, with 65 (62.5%), 13 (61.9%), and eight (42.1%) of them reporting pain lasting more than three months, respectively. The mean number of pain locations (SD) was 5.23 (3.95) for adults, 4.13 (3.48) for children/teenagers, and 3.15 (1.99) for children age 1–9 years, with lower limbs pain causing the greatest negative impact. More frequent pain-triggering factors were physical effort/movements (61, 74.4%) for adults and hemarthrosis for younger groups (children/teenagers: 14, 87.5%; children: 9, 69.2%). Bleeds yielded the highest mean pain intensity (adults: M [SD] = 5.67 [2.09]; children/teenagers: M [SD] = 5.69 [2.15]). Adults with pain revealed more anxiety (odds ratio [OR] = 1.698, P = 0.003) and depression (OR = 1.961, P = 0.025) and lower quality of life (OR = 0.928, P = 0.001).

Conclusions

The current findings highlight the high prevalence, duration, and frequency of pain at all ages, its potentially simultaneous acute and chronic nature, its likelihood to affect multiple locations concurrently, and its detrimental impact. Important insights concerning intervention needs are presented, ultimately contributing to the improvement of hemophilia-related pain management and patient care.

A new measure to assess pain in people with haemophilia: The Multidimensional Haemophilia Pain Questionnaire (MHPQ)

People with haemophilia (PWH) experience acute pain during joint bleeds and might develop chronic pain due to joint degeneration. However, there is a lack of standardized measures to comprehensively assess pain in PWH. This study aimed to develop a multidimensional questionnaire for haemophilia-related pain, the Multidimensional Haemophilia Pain Questionnaire (MHPQ), and to present initial validation data among adults.The questionnaire distinguishes between acute/chronic pain and queries about pain locations, duration, frequency, triggering factors, intensity, interference, strategies, specialists for pain management and satisfaction with treatment. An initial version was tested with 16 patients to ensure item comprehensibility and face validity. The final version was answered by 104 adults, with 82 (78.8%) reporting haemophilia-related pain in the previous year (mean age = 43.17; SD = 13.00). The non-response analysis revealed good item acceptability. Exploratory and confirmatory factor analysis (EFA/CFA), reliability (internal consistency, test-retest, inter-item and item-total correlations) and convergent validity were analysed for the intensity and interference dimensions of the questionnaire. A combined EFA with these two constructs supported a 2-factor structure distinguishing intensity (α = 0.88) from interference items (α = 0.91). CFA was tested for the interference dimension, demonstrating suitability for this sample. Item-total correlations were >0.30 on both dimensions and most inter-item correlations were <0.70. Test-retest reliability (n = 42) was good for intensity (r = 0.88) and interference (r = 0.73), and convergent validity was confirmed for most hypotheses (r>0.30).This questionnaire is a comprehensible tool, achieving a thorough assessment of relevant pain dimensions. The MHPQ can help guide treatment recommendations by highlighting relevant topics and contributing to more effective, integrated treatments.

Effectiveness of two psychological interventions for pain management, emotional regulation and promotion of quality of life among adult Portuguese men with haemophilia (PSY-HaEMOPEQ): study protocol for a single-centre prospective randomised controlled trial

INTRODUCTION

Haemophilia is a bleeding disorder associated with significant pain, emotional distress, quality of life (QoL) impairment and considerable healthcare costs. Psychosocial health and effective pain management are considered essential end points for optimal haemophilia care, but there is a significant gap in evidence-based treatments targeting these outcomes in people with haemophilia (PWH). Psychological interventions are cost-effective in promoting emotional well-being, QoL and pain control, although these have been scarcely used in haemophilia field. This investigation aims to evaluate the effectiveness of two psychological interventions for pain management, emotional regulation and promotion of QoL in PWH.

METHODS AND ANALYSIS

This is a single-centre parallel randomised controlled trial conducted at a European Haemophilia Comprehensive Care Centre in Portugal, with five assessment points: baseline (T0), postintervention (T1), 3 (T2), 6 (T3) and 12 (T4) months follow-up. Eligible adult males, with moderate or severe haemophilia A or B will be randomised to experimental (EG) or control (CG) group. Intervention is either cognitive-behavioural therapy (EG1) or hypnosis (EG2), both consisting of four weekly sessions following standardised scripts delivered by trained psychologists. Randomisation will be computer generated, allocation concealment will be guaranteed and outcome assessors will be blind to EG/CG allocation. Main outcomes are pain and haemophilia-related QoL and secondary outcomes include clinical (clotting factor replacement consumption, joint bleeding episodes, analgesic intake) and psychological (pain coping strategies, anxiety, depression, illness perceptions) variables, functional assessment of the joints, inflammatory biomarkers (cytokines, high-sensitivity C reactive protein) and white blood cell count.

ETHICS AND DISSEMINATION

This study was approved by the competent authorities and all procedures will comply with international ethical guidelines for clinical studies involving humans. Written informed consent will be obtained from all participants. The dissemination plan includes peer-reviewed scientific publications, conference participation and web and media coverage.

TRIAL REGISTRATION NUMBER

NCT02870452.

Medical co-morbidities of patients with haemophilia: pain, obesity and hepatitis C

Clinical care of patients with haemophilia (PWH) has progressed rapidly over the past decade. Current therapy has allowed patients with haemophilia to live longer and many patients are now experiencing the co-morbidities of the general population. In this review article, we focus on three common diseases states that affect PWH: chronic pain, obesity and hepatitis C. Pain has been a co-morbidity for many years and PWH often have unusual needs for chronic pain relief compared to the general population. Obesity is not only increasing in the general population but also in patients with hereditary bleeding disorders. The co-morbidity of obesity not only causes increased pain progression and joint damage but also affects the dosing of factor concentrates. Finally, hepatitis C is known to have infected the majority of patients who received non-virally inactivated pooled factor concentrates in the past. New treatment regimens have been developed that allow the nearly uniform cure of chronic hepatitis C with a short course of oral medications.