The role of the physiotherapist in the management of people with haemophilia: defining the new normal

Using evidence-based co-design to develop a hybrid delivered exercise intervention that aims to increase confidence to exercise in people with haemophilia

INTRODUCTION

Due to advances in treatments, people with haemophilia (PWH) are living longer. They are not as active as the general population due to joint damage and lack confidence to be active due to concerns about further bleeds and pain. There is a need to facilitate healthy aging through promotion of physical activity (PA) and exercise. Changing patient beliefs and increasing physical literacy and confidence to move are thought to be key to helping PWH become more active.

AIM

This paper describes the development of an exercise and behaviour change intervention to improve confidence to exercise in PWH.

METHODS

The 4-stage Medical Research Council framework for complex intervention development was used.

RESULTS

Stakeholders included 17 PWH and 7 physiotherapists working in haemophilia. Seven online focus group meetings were held. The final intervention is a hybrid 12-week physiotherapist led progressive exercise programme. Classes are 45 min including Pilates, High intensity interval training and balance elements, together with discussion sessions focusing on PA recommendations, the types and benefits of different exercise styles and the effects of PA, together with the effects of aging for PWH. The COM-B model of behaviour change was used to develop the intervention.

CONCLUSION

Co-design helps to produce an intervention that understands the stakeholders needs. Through this process the intervention developed to incorporate not only increasing PA but also confidence to exercise. The use of behaviour change theory identified the behaviour techniques included in the intervention and aims to increase physical literacy in this population.

Arthroscopic ankle surgery in people with haemophilia

INTRODUCTION

People with haemophilia (PWH) not administered primary haematological prophylaxis since childhood, that is, those treated haematologically on demand or not treated at all, often experience the degeneration of the ankles, leading to pain and functional impairment.

AIM

To analyse the outcomes and complications of arthroscopic ankle surgery performed on PWH.

METHODS

For this narrative review of the literature, a search was conducted in PubMed on 2, December 2023, using the keywords "haemophilia", "ankle" and "arthroscopy". Of the 29 articles identified, 15 specifically related to ankle arthroscopy in PWH were selected (inclusion criterion). The remaining articles did not meet this requirement (exclusion criterion) and were therefore eliminated.

RESULTS

Arthroscopic procedures (arthroscopic synovectomy, debridement and arthrodesis of the ankle) are increasingly used in the surgical treatment of haemophilic ankle arthropathy. Although arthroscopic ankle surgery offers good outcomes in patients with haemophilia, the procedure is not free of complications, which range from 7.9% for arthroscopic ankle debridement to 13.1% in arthroscopic ankle synovectomy and 17.8% in arthroscopic ankle arthrodesis, respectively. The non-union rate of arthroscopic ankle arthrodesis is 7.1% (2/28).

CONCLUSION

Although arthroscopic interventions in the haemophilic ankle (synovectomy, debridement, arthrodesis) offer good functional outcomes, they are associated with a non-negligible rate of complications. Arthroscopic ankle surgery in PWH is major surgery and should be treated as such.

Effectiveness of kinesiologic taping on function and pain in patients with hemophilia A

Background

Hemophilic arthropathy frequently results in musculoskeletal adjustments that impair functional capacity.

Aim

We investigated the effects of kinesiologic taping on patients with hemophilic arthropathy in this study.

Materials and Methods

Twenty-six patients were enrolled. Thirteen patients formed the Kinesiologic taping group (KT) and received the interventional protocol consisting of three kinesiologic taping sessions during three weeks; and 13 patients formed the control group (CG) and made three weeks of home exercises. All patients were evaluated using the Functional Independence Score in Hemophilia (FISH), Hemophilia Joint Health Score (HJHS), and Visual Analog Scale (VAS) at baseline, one week, and three weeks.

Results

The mean scores for the VAS, HJSS, and FISH differed significantly before and after 3 weeks in both groups (P < 0.001). However, the differences in medians after the treatment were significantly greater in the KT group than in the CG group (P < 0.001).

Conclusions

Kinesiologic taping was associated with physical improvement in hemophilia patients; however, also kinesiologic taping led to significant improvement in VAS scores.

Ultrasound Evaluation of Tendinopathy in Hemophiliac Patients for the Purpose of Rehabilitation Indications

BACKGROUND

Hemophilia is a inherited bleeding disorder that is characterized by intra-articular bleeding (hemarthrosis). The aim of the study was to evaluate the state of the satellite tendons of the target joints in the patient with hemophilic arthropathy and propose rehabilitation treatment with eccentric exercises.

METHODS

The tendons of the joints mainly affected by hemophilic arthropathy were evaluated by ultrasound. The ultrasound evaluation is associated with the use of evaluation clinical scales, such as the Hemophilia Joint Health Score (HJHS), the Functional Independence Score in Hemophilia (FISH), the Hemophilia Activity List (HAL), the DASH, the VISA-A, the VISA-P, and the VAS scale.

RESULTS

In 20 patients with hemophilic arthropathy, the thickness of the tendons that were examined was normal. In six subjects with severe joint damage, echostructural alterations were present, and signs of hyperemia and neo-vascularization were detected on color Doppler, as well as the presence of intratendinous calcifications.

CONCLUSIONS

The tendons of the target joints in patients with hemophilic arthropathy are compromised by the indirect biomechanical damage caused by the joint disease, and rehabilitation treatment with eccentric exercises can be considered safe and effective in improving the tenso-elastic properties of the tendons.

The evolution of physiotherapy in the multidisciplinary management of persons with haemophilia (PWH): A scoping review

INTRODUCTION

Haemophilia is a rare congenital bleeding disorder, and the most common manifestation is spontaneous bleeding in muscles and joints. Despite the benefits linked to recent and dramatic pharmacological advances at least in high income setting, many patients still develop musculoskeletal dysfunctions during their lifetime, which must be managed by physiotherapists in the frame of a multidisciplinary team. The aim of the scoping review is to map the available evidence by providing an overview on the past and present physiotherapy scenario in persons with haemophilia (PWH).

MATERIALS AND METHODS

The review was conducted according to the guidelines of the PRISMA extension for scoping reviews. Scientific articles on physiotherapy and sport interventions for PWH published from 1960 up to September 2021 have been included. Search was conducted on the e-databases PubMed and PEDro without restrictions for the study design.

RESULTS

Sixty eight articles were included, 52 related to rehabilitation and preventive physiotherapy, 16 to sport. The results have been reported in chronological order and divided into two categories: (1) rehabilitation and preventive physiotherapy; (2) sport activities.

CONCLUSIONS

This is the first scoping review on physiotherapy in haemophilia, based on the existing evidence on this topic which allowed us to underline how the role of the physiotherapist changed over time. Historically this specialist did intervene only after an acute bleed or surgical operation, but now he has a pivotal role in the multidisciplinary team that acts to improve from birth the quality of life of the PWH. His activity is also closely intertwined with sport promotion and supervision.

People with congenital bleeding disorders perspectives on why dentists refused to treat them: An exploratory qualitative study using a card sorting technique

AIMS

This qualitative study aimed to assess people with congenital bleeding disorders (CBDs) perspectives on why their dentists refused to treat them.

METHODS

Using validated and reliable questions, people with CBDs were asked about their attitude toward dental visit and teeth brushing, perceived thought about dentists' knowledge and skill in treating them, perceived dental anxiety, and perceived barriers toward receiving dental services. Free text responses were added to report reasons of why people with CBDs could not brush their teeth sometimes and why the dentists refused to treat them. An open card sorting method was used to analyze participants free text reports.

RESULTS

A total of 30 participants were recruited for the purpose of this qualitative study (70% adults and 30% children). Hemophilia A affected the majority of both groups. The majority of participants (n = 20, 67%) reported that they have been refused to be treated by their dentists (71% of adults versus 56% of children, as reported by their parents, p-value = 0.398). Adult participants reported that they have been refused to be treated by dentists due to fear of dentists from uncontrolled gingival bleeding, their dentists' beliefs that no dental treatment required for them, their thoughts that their dentists will refuse to treat them and difficulty of accommodating the dental visit with other medical appointments. Parents of children reported other reasons such as parents did not ask for dental treatments, difficulty of dental treatment to dentists, young age of patient, and poor accessibility to dental services due to long waiting list. Fear of adult participants from uncontrolled gingival bleeding (n = 4, 57%) and poor compliance of children toward teeth brushing (n = 2, 29%) were the reasons behind why they could not brush their teeth sometimes.

CONCLUSIONS

Among several reported reasons, fear of dentists from uncontrolled gingival bleeding was the most reported reason of why dentists refused to treat adults with CBDs. While other reasons were reported by parents of children with CBDs such as parents did not ask for dental treatment to their children, difficulty of dental treatment to dentists, young age of patients, and poor accessibility due to long waiting list.

Effectiveness of rehabilitation on pain and function in people affected by hemophilia

INTRODUCTION

Literature provides unclear evidence of the effectiveness of many physiotherapy interventions on pain intensity, quality of life, and functional ability in hemophilic patients, and suggests that rehabilitation programs should be focused on functional goals and the disability of patients.

AIM

The aim of the present study is to present the outcome of a case series of patients with hemophilia in which a rehabilitation program has been carried out on the basis of a specific individual patient's functional impairment.

METHODS

Fifty-one patients were enrolled: 32 patients (Rehab Group) received a rehabilitative treatment, 19 patients for different reasons (living far from the hospital, family problems) did not receive rehabilitation (Control Group). The rehabilitation program was planned with respect to the emergent problems: musculoskeletal pain, joint range of motion limitation, muscle flexibility, walking difficulties, the appearance of hematomas/hemartro, and postural problems. All the patients were assessed at baseline (T0), after 1 month (T1), and after 3 months (T2) through visual analogic scale for musculoskeletal pain, the Hemophilia Joint Health Score for joint range of motion, the Functional Independence Score in Hemophilia for disability, and postural assessment by visual inspection.

RESULTS

A significant reduction of pain and improvement of Hemophilia Joint Health Score and Functional Independence Score in Hemophilia score was found in the Rehab Group along with the follow-up. Pain in the Control Group was lower with respect to the other group at baseline and significantly decreased after 1 month.

CONCLUSION

A rehabilitation program focused on individual impairment of patients with hemophylia determined satisfying results in terms of pain control, functional, and disability improvement in 3 months follow-up.

The Role of Physiotherapy in the New Treatment Landscape for Haemophilia

The physiotherapist plays an essential role for people with haemophilia, an inherited bleeding disease responsible for musculoskeletal complications. Yet, with the advent of new and advanced therapies, the medical landscape is changing, and physiotherapy must adapt alongside. This paper considers whether there will still be a need for physiotherapy in the era of advanced therapies, and discusses ways in which services should evolve to complement emerging treatment paradigms for haemostasis in people with haemophilia. Ultimately, physiotherapy will remain an important element of care, even for people with little joint damage and low risks in the era of the new mild phenotype. However, competencies will need to evolve, and physiotherapists in both primary care and specialist treatment centres should work with haematology colleagues to develop more sensitive tools for detecting early joint changes. Physiotherapists will also play a crucial role in counselling and physically coaching, monitoring the musculoskeletal status of people with haemophilia who have transitioned to new treatments.