Psychosocial correlates of physical activity in adolescents with haemophilia

Study on Psychiatric Aspects, Psychosocial and Cognitive Functioning in Adolescents With Haemophilia

INTRODUCTION

Haemophilia, an inherited bleeding disorder, impacts physical and mental health. With improving survival, the focus is on mental health issues.

AIM

We examined and compared mental health issues in adolescents with haemophilia (AwH) in India with those of healthy controls. Additionally, we examined the relationship between quality of life and these mental health issues.

METHODS

Standardized assessments were applied (between 2021 and 2022) on male cases (n = 31) and controls (n = 31) to measure psychiatric morbidity, psychosocial, and neuro-cognitive functioning. Correlational analysis of quality of life with various mental health issues was also performed.

RESULTS

AwH had more emotional, social and behavioural problems, poor quality of life, more cognitive dysfunction, with no statistically significant difference in self-esteem as compared to healthy controls. There was a significant negative correlation between the quality of life and psychiatric morbidities, emotional and behavioural problems and cognitive dysfunction.

CONCLUSION

These findings corroborate evidence from other countries and emphasize the need for assessment of mental health issues and integration of mental health professionals in clinical services for AwH in India.

Promoting physical activity for people with haemophilia in the age of new treatments

Haemophilia treatment has seen great advances in recent years with an accompanied reduced risk of physical activity (PA) related bleeds. Based on its known health benefits, people with haemophilia (PWH) are currently encouraged to regularly engage in PA. However, this may not always translate to increased levels of PA. In this narrative review we aim to provide a brief overview of what is currently understood regarding PA levels and influences for the three broad age groups of children and adolescents, adults and older adults. We also provide recommendations for members of the haemophilia team on important aspects related to promotion of PA in their clinical practice. We highlight that PA behaviour is multifactorial and that many PWH still have limited access to adequate care. Whilst some still face unique challenges to being more physically active, overall, the barriers and facilitators to activity are very similar to that of the general population.

Exploration of the minimum necessary FVIII level at different physical activity levels in pediatric patients with hemophilia A

BACKGROUND

Physical activity can increase joint stability and reduce the risk of injury in hemophilia patients. There is limited clinical data on target trough FVIII levels during physical activity in hemophilia A patients. Hence, this study aimed to explore the target trough FVIII level required to avoid bleeding during different physical activities in hemophilia A patients.

METHODS

Patients with severe or moderate hemophilia A, who underwent pharmacokinetics (PK) tests at our center were enrolled in this study. Physical activities and clinical information such as bleeding were recorded. The FVIII level during physical activity was calculated by the WAPPS-Hemo.

RESULTS

A total of 105 patients were enrolled in this study. A total of 373 physical activities were recorded, of which 57.6% (215/373) was low-risk activities and the remaining 42.4% (158/373) was medium-risk activities. Most common physical activities were bicycling (59.0%), swimming (43.8%), running (48.6%), and jumping rope (41.0%). The FVIII trough level of low-risk physical activity was 3.8 IU/dl (AUC = 0.781, p = 0.002) and moderate-risk physical activity was 7.7 IU/dl (AUC = 0.809, p < 0.001). FVIII trough levels [low-risk activities: 6.1 (3.1, 13.2) IU/dl vs. 7.7 (2.3, 10.5) IU/dl, moderate-risk activities: 9.6 (5.8, 16.9) IU/dl vs. 10.2 (5.5, 11.0) IU/dl] were not statistically different between the mild arthropathy group and the moderate-severe arthropathy group. Multiple bleeding risk tended to increase with physical activities classified as moderate-risk (OR [95% CI]: 3.815 [1.766-8.238], p = 0.001).

CONCLUSION

The minimum necessary FVIII level increased with higher risk physical activity, irrespective of arthropathy.

Fitness enhances psychosocial well-being and self-confidence in young men with hemophilia: Results from Project GYM

INTRODUCTION

Contemporary hemophilia care supports physical activity, its benefits being well recognized. Despite recognition of the psychological challenges encountered by people with hemophilia, little is known about the psychological impact of physical fitness in this population.

AIM

To identify changes in psychological well-being in young men with hemophilia through participation in a gym program.

METHODS

This observational feasibility study of a 6-month gym participation program used validated questionnaires pre- and poststudy to evaluate motivation to exercise, physical activity levels, self-efficacy, self-esteem, and quality of life. Individual audio-recorded interviews about study participation and impact were transcribed verbatim and analyzed for recurring themes using thematic analysis.

RESULTS

Nineteen participants aged 18-25 years with hemophilia A or B (all severities ± inhibitor) consented to the study; two were lost to follow-up. There was a shift in motivation to exercise as shown by the Stages of Change grouping moving from contemplation to action and maintenance phases (p = 0.03). Self-efficacy overall scores showed a trend (p < 0.06) towards improvement. Median self-esteem scores improved from 22 (range 12-30, n = 19) to 25 (range 13-30, n = 17), a statistically significant change (p = 0.02). Three participants recorded scores below the accepted normal range before study, of whom two improved at study end. The key themes identified from the interviews were: fear, self-confidence, "being normal," pain, weight loss, ability, getting fitter.

CONCLUSIONS

The psychological wellbeing of young men with hemophilia improved during this study. This may have been related to participating in a gym-based, physical exercise program.

Feasibility, safety and acceptability of select outcome measures in a physiotherapy study protocol for boys with haemophilia

Background

There is a lack of functional performance measures for children and young people with haemophilia (CYPwH) with associated control data from typically developing boys (TDB). The literature advocates development of a core set of outcome measures for different chronic conditions. As medical treatment improves, CYPwH are experiencing better outcomes; therefore, more challenging measures are required to monitor physical performance. Such testing is not performed routinely, due to practical and safety concerns.

Aim

Evaluate the feasibility, safety and acceptability of select outcome measures as part of a study protocol testing CYPwH; including myometry, 10 metre incremental shuttle walk test (10-m ISWT), iSTEP (an incremental step test, with data from TDB), and 1 week of accelerometry-wear at home.

Methods

Sixty-six boys aged 6–15 years with mild, moderate or severe haemophilia A or B (including inhibitors) attending routine clinics at Great Ormond Street Hospital were approached to participate. Descriptive statistics and content analysis were used to assess outcomes of feasibility, safety and acceptability, which included recruitment/retention rates, protocol completion within routine appointment timeframes, performance testing without serious adverse events/reactions (SAE/SARs), and acceptability to CYPwH of high-level performance measures.

Results

Outcomes were met: 43 boys completed testing at clinic review (Jan–Nov 2018) within a 10-month timeframe, retention was 95% at completion of protocol and no SAE/SARs were reported throughout testing.

Conclusion

Feasibility, safety and acceptability of the study protocol have been established in this population. Both high-level performance tests, iSTEP and 10-m ISWT, were an acceptable addition to boys’ routine clinic appointments and could be safe, acceptable choices of outcome measure as part of a core set of tests for CYPwH. Further investigation of the psychometric properties for the iSTEP is now justified, in order for it to be used as a standardised, validated, reliable outcome measure in clinical or research settings.

Trial registration

Retrospectively registered on September 3, 2019, on ClinicalTrials.gov (ID: NCT04076306).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00831-1.

A systematic review of physical activity in people with haemophilia and its relationship with bleeding phenotype and treatment regimen

INTRODUCTION

Although the measurement of physical activity (PA) amongst people with haemophilia (PWH) has become increasingly widespread in recent years, the relationship between PA and bleeding phenotype remains poorly understood. In addition, the influence of various treatment regimens on this relationship has not been defined.

AIM

This review aimed to systematically assess the data that are available regarding PA levels amongst PWH, as well as the relationship between PA and bleeding.

METHODS

A systematic search of the online databases EMBASE, Cochrane, MEDLINE Ovid, CINAHL and Web of Science was conducted by two independent reviewers. Quality assessment was undertaken using the AXIS Critical Appraisal Tool for Cross-sectional Studies and the STROBE checklist.

RESULTS

Of 1902 sources identified overall, 36 articles were included. Low-to-moderate transparency of reporting and various sources of bias were identified. PA levels varied amongst heterogeneous samples of PWH. The relationship between PA and bleeds was inconclusive, although there was evidence that improvements in treatment over recent decades have appeared to enable PWH to become more physically active.

CONCLUSION

Based upon the limited available evidence, the relationship between PA and bleeding phenotype in PWH remains unclear. However, with the development of improved prophylaxis treatment regimens in recent years, there is evidence that PA levels have increased, especially amongst people with severe haemophilia. The use of validated outcome measures of PA and more robust reporting of bleeds and treatment regimen are warranted in future research, especially in a rapidly evolving era of new treatments for PWH.

Lower physical activity and altered body composition in patients with haemophilia compared with healthy controls

Introduction

Patients with haemophilia (PWH) have traditionally been discouraged from engaging in sports and strenuous exercise activities, due to the perceived risk of bleeding complications. This puts PWH at an increased risk to become overweight or obese. However, the benefits of many forms of physical activity seem to outweigh their risks, although activities with significant trauma risk should be avoided.

Aim

To evaluate physical activity patterns and body composition of adult PWH.

Methods

This cross‐sectional study compared data on physical activity from tri‐axial accelerometers and body composition of 18 male adult PWH (aged 18–49 years) on prophylactic replacement therapy and without acute joint bleedings to those of 24 healthy age‐matched controls, by means of Mann‐Whitney‐U‐Tests.

Results

Median moderate‐to‐vigorous physical activity was significantly (p = .000) lower in PWH (34.6 min/day) than in healthy controls (65.2 min/day). Body mass index was almost similar between PWH and controls (25.1 vs 24.2 kg/m², p = .431). Yet, we found a consistent trend towards less desirable outcomes across body composition parameters, such as median body fat rate (23.5 vs 17.0%, p = .055) in PWH, compared with controls.

Conclusion

Although physical activity has been recommended for PWH since the mid‐1970s, the physical activity engagement of adult PWH was still severely limited, possibly due to over‐cautiousness but presumably also in consequence of chronic pain. Poor physical activity engagement may well be expected to contribute to the increased body fat and decreased leg muscle mass. Consequently, policies should focus on improving the knowledge and motivation of PWH to engage in health‐enhancing physical activity.

Sports participation and sports injuries in Dutch boys with haemophilia

INTRODUCTION

Sports participation in children with hemophilia is generally considered to be associated with increased injury risk, which is generally considered highest in severe hemophilia.

AIM

To assess sports participation according to age and severity in children with hemophilia and its association with sports injuries.

METHODS

In a retrospective single-center study, sports participation, injuries, and bleeding data from three consecutive annual clinic visits were collected for young patients with hemophilia (PWH, aged 6-18). Sports in categories 2.5 and 3 of 3 according to the National Hemophilia Foundation classification were considered high-risk. Groups were compared using chi-square testing.

RESULTS

105 PWH (median age: 13(IQR 10-14); 53% severe; bleeding rate: 1/y) were identified; three were unable to perform sports and were excluded. The majority of PWH (77%) played sports weekly, of which 80% high-risk sports. Sports participation (median 3.0x/wk), and the proportion of injured PWH was similar in severe (42%) and non-severe (33%) PWH. Sports injuries were rare (65% no injuries in 3 years, median 0/y (IQR 0-1)). Annually, PWH did not report more injuries (15%) than age-matched boys (28%). Sports injuries were not associated with frequency and type of sports.

DISCUSSION

This retrospective study showed high sports participation (including high-risk sports) and low injury rates. Sports participation was similar across severities and injury rates were not higher than among the general population. Injuries were not associated with frequency or type of sports. A prospective study with objective assessment of sports participation and injuries is warranted to confirm these findings and avoid recall bias.

Physical Activity Monitoring and Acceptance of a Commercial Activity Tracker in Adult Patients with Haemophilia

Physical activity (PA) is highly beneficial for people with haemophilia (PWH), however, studies that objectively monitor the PA in this population are scarce. This study aimed to monitor the daily PA and analyse its evolution over time in a cohort of PWH using a commercial activity tracker. In addition, this work analyses the relationship between PA levels, demographics, and joint health status, as well as the acceptance and adherence to the activity tracker. Twenty-six PWH were asked to wear a Fitbit Charge HR for 13 weeks. According to the steps/day in the first week, data were divided into two groups: Active Group (AG; ≥10,000 steps/day) and Non-Active Group (NAG; <10,000 steps/day). Correlations between PA and patient characteristics were studied using the Pearson coefficient. Participants' user experience was analysed with a questionnaire. The 10,000 steps/day was reached by 57.7% of participants, with 12,603 (1525) and 7495 (1626) being the mean steps/day of the AG and NAG, respectively. In general, no significant variations (p > 0.05) in PA levels or adherence to wristband were produced. Only the correlation between very active minutes and arthropathy was significant (r = -0.40, p = 0.045). Results of the questionnaire showed a high level of satisfaction. In summary, PWH are able to comply with the PA recommendations, and the Fitbit wristband is a valid tool for a continuous and long-term monitoring of PA. However, by itself, the use of a wristband is not enough motivation to increase PA levels.

Correlation of Body Mass Index with Pelvis and Lumbar Spine Alignment in Sagittal Plane in Hemophilia Patients

Introduction: Concern about weight gain among people has been high due to negative health consequences in addition to the increasing prevalence of the problem. Overweight and obesity also occur in patients with hemophilia. Analysis of literature shows that increased body weight might have a biomechanical effect on the spatial orientation of the pelvis and the lumbar spine. The aim of this study was to determine the correlation between body mass index (BMI) and the parameters characterizing the alignment of the sacrum (SS, sacral slope), the pelvis (PT, pelvic tilt; PI, pelvic incidence) and the angle value of lumbar lordosis (LL, lumbar lordosis) assessed in the sagittal plane among patients with hemophilia. Materials and methods: A total of 49 patients were subjected to the study, 23 of whom met the inclusion criteria. Body weight and height were measured. Measurement of the angle values of indicators characterizing the position of the lumbar–pelvic complex was established based on X-ray imaging analysis. Results: Analysis of the correlation between the BMI and sacral, pelvic, and lumbar indicators evaluated in the sagittal plane in the study group of patients with hemophilia showed a correlation between BMI and SS (r = 0.48). SS values were significantly and positively related to PI (r = 0.6; p = 0.002) and LL (r = 0.46; p = 0.02). The results obtained indicate the BMI relationship with the setting of the sacrum in the sagittal plane (SS). After adjusting for the knee flexion contracture, the correlation on the border of significance (b = 0.73, p = 0.07) between the body mass index and the spatial orientation of the pelvis and the spine was revealed. Conclusion: We hypothesize that increased body weight among people with hemophilia might have an effect on the positioning of the lumbosacral region. Therefore, it is believed that preventing obesity among people with hemophilia can contribute to a smaller number of intra-articular hemorrhages and better orthopedic condition of the limb joints, and thus could avoid changes in the lumbosacral region as well as their consequences.

Sports participation and physical activity in adult Dutch and Swedish patients with severe haemophilia: A comparison between intermediate- and high-dose prophylaxis

Introduction

Differences in treatment and outcome have been reported for persons with haemophilia (PWH) on intermediate‐dose (Dutch) and high‐dose (Swedish) prophylaxis, but the potential influence of sports participation has not been considered.

Aim

To compare sports participation and clinical outcome between adult Dutch and Swedish PWH.

Methods

Self‐reported sports participation (type and frequency per week), physical functioning (SF‐36_PF: 100‐0), joint status (HJHS: 0‐144), perceived limitations (HAL_sum: 100‐0) and physical activity (IPAQ) were recorded. Sports were classified according to National Haemophilia Foundation classification (5 categories, highest two were classified as high‐risk sports). Sports participation and clinical outcome were compared according to country and age (18‐22, 23‐29, 30‐40 years) using non‐parametric tests and Spearman correlations (rho).

Results

Seventy‐one adult PWH (NL: 43, SWE: 28) completed sports questionnaires (mean age: 26 years). All participants engaged in sports, including 59.2% in high‐risk sports (33.9% twice weekly). Dutch PWH showed a significant age‐related decline in (high‐risk) sports participation (7x/wk in PWH 18‐22 years to 2x/wk in PWH 30‐40 years, P < 0.05), joint health (HJHS: median 2‐15.5, P < 0.01) and physical functioning (SF‐36_PF: median 100 to 77.5, P < 0.01), while Swedish did not. Sports participation was not associated with bleeding (Spearman's rho = −0.119).

Conclusion

All participants reported sports participation, including 59.2% in high‐risk sports. Dutch PWH treated with intermediate‐dose prophylaxis showed an age‐related decline in sports participation, joint status and physical functioning, whereas Swedish PWH on high‐dose prophylaxis did not. Sports participation was not associated with bleeding.

Sports participation and physical activity in patients with von Willebrand disease

Introduction

Patients with bleeding disorders may experience limitations in sports participation and physical activity. Several studies on sports participation have been performed in haemophilia patients, but studies in patients with von Willebrand disease (VWD) are lacking.

Aim

We assessed the sports participation and physical activity of a large cohort of VWD patients.

Methods

Patients were included from the “WiN study.” All patients completed a questionnaire on sports participation, physical activity, quality of life and bleeding symptoms (Tosetto bleeding score).

Results

From the 798 included patients, 474 had type 1, 301 type 2 and 23 type 3 VWD. The mean age was 39 ± 20 (standard deviation) years. Five hundred and fifty‐two patients (69.3%) participated in various types of sports. Type 3 VWD patients more often did not participate in sports due to fear of bleeding and physical impairment, respectively, OR = 13.24 (95% CI: 2.45‐71.53) and OR = 5.90 (95% CI: 1.77‐19.72). Patients who did not participate in sports due to physical impairment had a higher bleeding score item for joint bleeds 1.0 (±1.6) vs 0.5 (± 1.1) (P = 0.036). Patients with type 3 VWD and patients with a higher bleeding score frequently had severe limitations during daily activities, respectively, OR = 9.84 (95% CI: 2.83‐34.24) and OR = 1.08 (95% CI: 1.04‐1.12).

Conclusion

The majority of VWD patients participated in sports. Patients with type 3 VWD, a history of joint bleeds and a more severe bleeding phenotype frequently experienced limitations in sports participation and physical activities during daily life.

Balance, falls, and exercise: Beliefs and experiences in people with hemophilia: A qualitative study

BACKGROUND

Prior research has established that falls are commonplace in adults with hemophilia, and advises that physical therapy and exercise are successful in fall prevention. Recognizing obstacles and catalysts to physical therapy and exercise in people with hemophilia may augment the efficacy of efforts to prevent falls in this population.

OBJECTIVES

To learn about the experiences and ideas of patients with hemophilia, especially associated with balance, falls, and exercise.

METHODS

Semi-structured interviews with 14 adult patients with hemophilia were performed. The interviews were coded for themes founded on the study aims.

RESULTS

Most subjects described difficulty with balance, often ascribed to joint problems. They believed that staying strong and fit could positively influence balance, but expressed concerns and fear related to falling. Those who exercised regularly did not view exercise as hazardous, while those who did not dependably exercise articulated worry that dangers of exercise may offset the benefits. The most common obstacle to exercise was pain and having someone to exercise with was often described as an enabler. Barriers to partaking in physical therapy included weak proof of its success and distrust in the therapist. Positive physical therapy experiences in the past and the connection with the therapist were reported as facilitators.

CONCLUSIONS

People with hemophilia describe some attitudes and experiences that are unique to hemophilia while others are found in the general population. Attending to fear, pain, and support for interventions, while encouraging a robust therapeutic alliance and a plan for routine exercise may aid fall prevention behaviors.

Physical activity in individuals with haemophilia and experience with recombinant factor VIII Fc fusion protein and recombinant factor IX Fc fusion protein for the treatment of active patients: a literature review and case reports

The World Federation of Hemophilia and the National Hemophilia Foundation encourage people with haemophilia (PWH) to participate in routine physical activity. The benefits of physical activity for PWH include improvements in joint, bone, and muscle health. Accordingly, a number of studies suggest that levels of physical activity among PWH are similar to those of their healthy peers, especially among individuals who began prophylaxis at an early age (≤3 years). Importantly, several studies found either no increased risk or only a transient increase in risk of bleeding with more intensive physical activity compared with less intensive physical activity. Data on optimal prophylaxis regimens for PWH who participate in physical/sporting activities; however, remain sparse. Long-acting recombinant factor VIII Fc fusion protein (rFVIIIFc) and recombinant factor IX Fc fusion protein (rFIXFc) demonstrated efficacy for the prevention and treatment of bleeding episodes in Phase 3 clinical trials of participants with haemophilia A and B, respectively, with most individuals able to maintain or increase their physical activities. This manuscript reviews the current literature that describes physical activity in PWH. Additionally, case studies are presented to provide supplemental information to clinicians illustrating the use of rFVIIIFc and rFIXFc in physically active patients with haemophilia A and B, respectively. These case reports demonstrate that it is possible for patients to be physically active and maintain good control of their haemophilia with extended interval prophylactic dosing using rFVIIIFc or rFIXFc.

Strategies to encourage physical activity in patients with hemophilia to improve quality of life

Hemophilia is a bleeding disorder caused by a congenital abnormality of blood coagulation. Until the mid-1970s, patients with hemophilia (PWH) were advised to refrain from physical activity (PA) because of a perceived increased risk of bleeding. Since then, PA, which is recognized as being essential for health maintenance, is now recommended by the World Federation of Hemophilia. Moreover, a number of studies reported that PA can improve treatment efficacy and prevent bleeding in PWH. Physical assessment and intervention in PA are currently used in clinical practice. However, the necessity of PA is not emphasized, and many PWH generally have low- to- no PA. Therefore, a behavior change approach to encourage patient motivation is becoming ever more important. In this article, we review articles addressing PA in PWH and discuss strategies to encourage PA through a behavior change approach by focusing on factors relevant to hemophilia, such as benefits and bleeding risk of PA, risk management of bleeding, PA characteristics, and difficulty with exercise adherence. The trust relationship between clinicians and patients, a transtheoretical model of behavior change, and motivation theory as approaches to promote PA are introduced. Finally, we review a case report of the clinical success of a behavior change approach to promote PA. Many PWH find it difficult to continue PA because of aging, fear of bleeding, insufficient recognition of PA benefits, and psychological problems. Therefore, it is essential and important to perform prophylaxis with PWH and to heighten their understanding of the benefits and risks of PA, before initiating the exercise regimen. For those patients who find it difficult to participate in PA, it is necessary to plan individual-based behavior change approach and encourage self-efficacy.