Effects of a supervised therapeutic exercise program on musculoskeletal health and gait in patients with haemophilia: A pilot study

Comparison of Efficiency of Closed Kinetic Chain Exercises Versus Proprioceptive Exercises in Improving Balance and Gait in People With Hemophilia: Protocol for a Randomized Controlled Trial

BACKGROUND

Inherited bleeding disorders involve prolonged bleeding due to clotting protein deficiencies, with hemophilia A and B being the most common types. The severity of bleeding in people with hemophilia depends on the deficient factor level. Treatment includes coagulation factor concentrates, nonreplacement preparations, gene therapies, and physiotherapy, whereby bleeding is prevented, symptoms are reduced, and the quality of life is improved. Closed kinetic chain exercises improve joint stability and neuromuscular control by stabilizing the proximal base, making them favored in musculoskeletal rehabilitation. Proprioceptive exercise training improves the sensorimotor system's adaptability and injury prevention through tailored programs involving progressively complex movements and surfaces.

OBJECTIVE

The aim of this study is to investigate the effects of closed kinetic chain exercises and proprioceptive exercise training on improving balance and walking in people with hemophilia.

METHODS

This study is a 3-arm, parallel-group randomized controlled trial with 63 people with hemophilia aged 13-25 years who meet the inclusion criteria. The primary outcome measures are medio-lateral swing, anterior-posterior swing, walking speed, and Hemophilia Joint Health Score. Secondary outcome measures are kinematic assessment of gait, one-leg stand test, 6-minute walk distance (6MWD) test, proprioception assessment, and the Functional Independence Score in Hemophilia. Participants will be evaluated with the Biodex balance system for postural sway, 10-meters walking test for gait speed, Hemophilia Joint Health Score for joint health, Kinovea 2D motion analysis for kinematic evaluation of gait, one-leg stand test for balance measurement, 6MWD for functional capacity, digital goniometer for proprioception, and Functional Independence Score in Hemophilia for functional independence. Participants will be randomly assigned to a closed kinetic chain exercise group, a proprioceptive exercise group, or a control group. All participants in exercise training groups will receive a 30-minute education session on joint protection techniques and energy conservation prior to the first exercise session. Closed kinetic chain exercises will include progressive lower limb exercises of approximately 45 minutes each session. Proprioceptive exercise training will focus on vibration training; reposition exercises and proprioception exercises will be administered to increase proprioceptive input for the same duration as the other group. The control group will receive no intervention. All participants will undergo 24 exercise sessions (2 days a week for 12 weeks). After the treatment, the initial measurements will be repeated.

RESULTS

This study began in September 2023 and is scheduled to be completed in May 2025. A total of 34 participants have completed the study to date.

CONCLUSIONS

This study will investigate the effects of 2 different exercises on functional parameters in people with hemophilia. The effects of different exercise protocols on parameters such as postural sway, walking speed, and joint health will be evaluated. It is predicted that both exercise methods may have positive effects on balance and gait.

TRIAL REGISTRATION

Clinical Trials.gov NCT05879549; https://clinicaltrials.gov/study/NCT05879549.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/66770.

Global trends in hemophilic arthropathy research: a bibliometric and visualization analysis

Background

Hemophilic arthropathy (HA), a common complication of hemophilia caused by recurrent hemarthrosis, significantly impacts patients' quality of life. Despite ongoing research, a comprehensive overview of research trends for HA is lacking. Therefore, this study utilizes bibliometrics and knowledge mapping techniques to visually analyze the current status and developmental trends of HA-related research, and analyzed and predicted future research hotspots.

Methods

A bibliometric analysis was conducted using the Web of Science Core Collection database. Data on publications, author names, countries, research institutions, journals, and keywords were extracted and visualized using Bibliometrix, VOSviewer, and CiteSpaces.

Results

The number of HA-related publications has increased steadily over time. United States was found to be the leading country in terms of publications and international collaborations. HEMOPHILIA was found to be the most influential journal and Hospital Universitario La Paz to be the leading institution conducting HA-related research. Rodriguez-Merchan EC was identified as the most prominent researcher in the field. Keyword analysis identified five main research clusters, namely, quality of life and management, pathogenesis, classification and functional assessment, replacement surgery, and ankle arthritis treatment.

Conclusion

This bibliometric analysis provides a comprehensive overview of the research trends for HA. Future studies must focus on elucidating the underlying mechanisms of HA, developing early diagnostic biomarkers, and exploring personalized treatment strategies to improve patient outcomes. Our study offers valuable insights to researchers to facilitate the identification of emerging trends and prioritization of future research directions.

Low frequency physiotherapy on joint health, hemarthrosis, walking, balance and reaction time in hemophilic arthropathy: a controlled trial

BACKGROUND

Physiotherapy is recommended for people with hemophilic arthropathy (PwHA) to improve musculoskeletal health and is typically administered in 2 or 3 sessions per week. We aimed to investigate the effects of once a week comprehensive physiotherapy and home exercise on musculoskeletal system of PwHA.

METHODS

In this study 19 young PwHA with knee and/or ankle were non-randomly divided into two groups: The Home Exercise Group (HEG) and the Comprehensive Physiotherapy Group (CPG). Joint health was evaluated with the Hemophilia Joint Health Score (HJHS), muscle strength (MS) with manual muscle tester, range of motion (ROM) with universal goniometer, pain with Numerical Pain Scale (NPS). The following functional tests were used: 6 min Walking Test (6MWT) for walking capacity, Functional Reach Test (FRT) for dynamic balance and Fitlight® system for visuomotor reaction time (VMRT). The frequency of hemarthrosis (FoH) in the last 6 weeks was obtained from the self-recorded data. The CPG received comprehensive physiotherapy once a week, including manual therapy, neuromuscular electrical stimulation and supervised exercises, and they performed home exercises for the other two days of the week. The HEG only performed home exercises 3 days a week. All the treatments lasted 6 weeks and evaluations were repeated.

RESULTS

Compared with the HEG, the CPG significantly ameliorated for NPS, FoH, HJHS, VMRT (time and mean), 6MWT, all MS and several ROMs. CPG significantly improved in all outcomes except for 1 ROM. The HEG significantly improved in FoH, HJHS, VMRT (time), 6MWT and MS, but not in the ROMs.

CONCLUSION

Comprehensive physiotherapy once a week and continuing home exercise significantly improve joint health, functionality and balance, and reduce pain and hemarthrosis in PwHA.

TRIAL REGISTRATION

The study was registered at Clinicaltrials.gov (Study ID NCT06331091, retrospectively registered).

A clinical practice guideline for primary care physiotherapy in patients with haemophilia

INTRODUCTION

As a result of centralisation of haemophilia care to a limited number of intramural settings, many persons with haemophilia have to travel long distances to attend their haemophilia specialised treatment centre. However, regular physiotherapy treatment can be provided by primary care physiotherapists in the person's own region. Due to the rarity of the disease most primary care physiotherapists have limited experience with this population. This study aims to provide a clinical practice guideline for primary care physiotherapists working with persons with bleeding disorders.

METHOD

A list of the most urgent key-questions was derived from a previous study. Literature was summarised using the grading of recommendations assessment, development, and evaluation (GRADE) evidence-to-decision framework. Recommendations were drafted based on four 90 min consensus meetings with expert physiotherapists. Recommendations were finalised after feedback and >80% consensus of all stakeholders (including PWH, physiotherapists, haematologists and the corresponding societies).

RESULTS

A list of 82 recommendations was formulated to support primary care physiotherapists when treating a person with a bleeding disorder. These recommendations could be divided into 13 categories: two including recommendations on organisation of care, six on therapy for adult patients with bleeding disorders and five on therapy adaptations for paediatric care. Therapy recommendations included treatment after a joint- or muscle bleed, haemophilic arthropathy, chronic synovitis, non-haemophilia related conditions and orthopaedic surgery.

CONCLUSION

An evidence-based practice guideline, based on current evidence from literature and clinical expertise, has been developed for primary care physiotherapists treating a person with haemophilia. To improve care, the recommendations should be implemented in daily practice.

Exercise capacity in people with haemophilia: A systematic review

INTRODUCTION

Exercise capacity has been established as a protective factor against joint impairment in people with haemophilia (PWH). However, little is known about how exercise capacity is affected in PWH.

AIM

To analyse exercise capacity, as assessed by standardised laboratory or field tests in PWH.

METHODS

A systematic review was conducted to identify manuscripts investigating physical capacity in PWH. An electronic search of PubMed/MEDLINE, Embase, Web of Science, CENTRAL and CINAHL was conducted from inception to 13 April, 2022. Two independent reviewers performed data extraction and assessed study quality using the critical appraisal tools of the Joanna Briggs Institute.

RESULTS

Nineteen studies with 825 patients were included. Most studies used the six-min walk test (6MWT) or peak/maximal oxygen consumption (VO₂ max). In children, the distance walked ranged from 274 ± 36.02 to 680 ± 100 m. In adults, the distance walked ranged from 457.5 ± 96.9 to 650.9 ± 180.3 m. VO₂ max ranged from 37 ± 8 to 47.42 ± 8.29 ml kg^-1  min^-1 . Most studies reported lower values of exercise capacity compared to standardised values. Overall, the quality of the studies was moderate.

CONCLUSION

Most of the studies showed that PWH have lower exercise capacity compared to reference values of 6MWT or VO₂ max. Based on these results, it is necessary to emphasise in both the promotion and the prescription of physical exercise in PWH.