Study of physical function in adolescents with haemophilia: The SO-FIT study

INTRODUCTION

Contemporary haemophilia care demands Patient-Reported Outcomes. SO-FIT is a UK multi-centre study, assessing self-reported function, health-related quality of life (HRQoL) and joint health in boys with severe haemophilia.

METHODS

Subjective physical function (PedHAL, HEP-Test-Q) and HRQoL (Haemo-QoL Short Form [SF]) were assessed alongside joint health using the objective Haemophilia Joint Health Score (HJHS v2.1). Demographic and clinical data were collected.

RESULTS

Data from 127 boys mean age 12.38 ± 2.5 (range 8-17) treated at 16 sites were analysed. One-hundred-and-thirteen had haemophilia A, 25/9 past/current inhibitor, 124 were treated prophylactically (46.8% primary) and three on-demand. In the preceding 6 months, boys reported median 0 joint bleeds (range 0-8) with a median HJHS score of 1 (range 0-30). Boys reported good physical functioning; HEP-Test-Q (M = 80.32 ± 16.1) showed the highest impairments in the domain "endurance" (72.53 ± 19.1), in PedHAL (M = 85.44 ± 18.9) highest impairments were in the domains "leisure activities & sports" (M = 82.43 ± 23.4) and "lying/sitting/kneeling/standing" (M = 83.22 ± 20.3). Boys reported generally good HRQoL in Haemo-QoL SF SF (M = 22.81 ± 15.0) with highest impairments in the domains "friends" (M = 28.81 ± 30.5) and "sports & school" (M = 26.14 ± 25.1). HJHS revealed low correlations with the Haemo-QoL SF (r = .251, P < .006), the PedHAL (r = -.397, P < .0001) and the HEP-Test-Q (r = -.323, P < .0001). A moderate correlation was seen between HEP-Test-Q and Haemo-QoL SF of r = -.575 (P < .0001) and between PedHAL and Haemo-QoL SFr = -.561 (P < .0001) implying that good perceived physical function is related to good HRQoL.

CONCLUSIONS

The SO-FIT study has demonstrated that children with severe haemophilia in the UK report good HRQoL and have good joint health as reflected in low HJHS scores.

Relationship between physical function and biomechanical gait patterns in boys with haemophilia

INTRODUCTION

The World Federation of Haemophilia recommends joint and muscle health is evaluated using X-ray and magnetic resonance imaging, together with clinical examination scores. To date, inclusion of performance-based functional activities to monitor children with the condition has received little attention.

AIM

To evaluate test-retest repeatability of physical function tests and quantify relationships between physical function, lower limb muscle strength and gait patterns in young boys with haemophilia.

METHODS

Timed 6-minute walk, timed up and down stairs, timed single leg stance, muscle strength of the knee extensors, ankle dorsi and plantar flexors, together with joint biomechanics during level walking were collected from 21 boys aged 6-12 years with severe haemophilia.

RESULTS

Measures of physical function and recording of muscle strength with a hand-held myometer were repeatable (ICC > 0.78). Distances walked in six minutes, time taken to go up and down a flight of stairs and lower limb muscle strength correlated closely with ankle range of motion, together with peak knee flexion and ankle dorsi and plantarflexion moments during walking (P < 0.05).

CONCLUSION

Alterations in gait patterns of boys with haemophilia appear to be associated with changes in performance of physical function and performance seems to depend on their muscle strength. Timed 6-minute walk test, timed up and down steps test and muscle strength of the knee extensors showed the strongest correlation with biomechanical joint function, and hence might serve as a basis for the clinical monitoring of physical function outcomes in children with haemophilia.

Factors affecting the Haemophilia Joint Health Score in children with severe haemophilia

Joint damage from bleeding episodes leads to physical or functional limitations in people with haemophilia. Various factors may influence the frequency and severity of joint damage. This study examined whether age, prophylaxis, history of high-titre inhibitors (HTI) and bleeding events influenced the Haemophilia Joint Health Score (HJHS) in children. Medical and physiotherapy notes of boys with severe haemophilia, aged 4-18 years, were reviewed to identify factors associated with increased HJHS. The HJHS of 83 boys (median age: 11) ranged from 0 to 25, with 44/83 (53%) having a score of zero. The median HJHS was 0 (mean 2.6). In the non-HTI group, the HJHS for boys on late prophylaxis was 2.68 times higher than those who started early and the HJHS was on average 10% higher for every additional recent bleed. In this group the odds of having a zero score fell by 30% for every year increase in age. Boys with a history of HTI had higher HJHS scores than the non-HTI group, and age, number of recent bleeds and tolerized status were positively associated with HJHS. The score rose on average by 28% for every year of age and by 76% for non-tolerized boys. This study provides further evidence supporting early prophylaxis use and the importance of immune tolerance therapy. The HJHS is a useful tool for identifying and tracking changes in joint health with respect to therapy or disease progression. With improvements in haemophilia treatment, the disproportionate number of zero scores will continue to make interpretation of the HJHS challenging.

Management of muscle haematomas in patients with severe haemophilia in an evidence-poor world

Treatment studies in haemophilia focus on joint bleeds; however, some 10-25% of bleeds occur in muscles. This review addresses management of muscle haematoma in severe haemophilia, defines gaps in the published evidence, and presents a combined clinician and physiotherapist perspective of treatment modalities. The following grade 2C recommendations were synthesized: (i) Sport and activity should be based on individual factor levels, bleeding history and physical characteristics, (ii) Musculoskeletal review aids the management of children and adults, (iii) 'Time to full recovery' should be realistic and based on known timelines from the healthy population, (iv) Diagnosis should be carried out by both a clinician and physiotherapist, (v) Severe muscle bleeds should be treated similarly to surgical patients: a 50% trough for 10-14 days followed by high-level prophylaxis, (vi) Protection, rest, ice, compression and elevation should be implemented in the acute stage, and (vii) Physiotherapy and rehabilitation should be divided into: control of haemorrhage (phase 1); restoration of Range of Movement (ROM) and strength (phase 2); functional rehabilitation and return to normal living (phase 3). Recommendations specifically for inhibitor patients include: (i) Minor to moderate bleeds should be managed by home-treatment within 1 h of bleed onset using either one injection of rFVIIa 270 μg kg(-1), or two to three injections of rFVIIa 90 μg kg(-1) (2-3 h intervals), or FEIBA 50-100 U kg(-1) (repeated at 12-hourly intervals, if necessary) and (ii) Severe muscle bleeds should be supervised by the treatment centre and include bypassing agents until clinical improvement is observed.

Long-term consequences of intracranial haemorrhage in children with haemophilia

Intracranial haemorrhages (ICH) in children with haemophilia are rare, and the outcome is variable, ranging from no apparent impairment to death. The aim of this investigation was to identify if children with haemophilia and ICH, have any long-term problems with motor function, visual motor integration or strengths and difficulties compared with a control group. A review of the Haemophilia Database at Great Ormond Street Hospital for Children NHS Trust was undertaken to identify boys with haemophilia and a history of ICH, as well as a control group of peers with no such history. Boys were born between January 1994 and December 2002. All boys were assessed using the movement Assessment Battery for Children, the Developmental Test of Visual Motor Integration and The Strengths and Difficulties Questionnaire as standardized assessments of motor competence, visual motor integration and behavioural difficulties. Six boys with haemophilia and ICH and 11 controls (mean age: 7 years; range: 4-12 years) were assessed. Children with ICH were significantly more likely to have problems with motor function and visual motor integration (Fisher's exact: P < 0.05). In addition, they had a tendency towards more problems with strengths and difficulties than their peer group (Fisher's exact: P = 0.06). Five of the six boys who had sustained an ICH were in mainstream schools; four requiring assistance with their education. The results of this small study suggest that ICH may signify long-term consequences for boys with haemophilia. The multidisciplinary team need to be aware of the rare but potentially important impact on motor function, visual motor integration and behaviour, which may inhibit the child from functioning optimally. An agreed comprehensive battery of assessments in collaboration with schools and healthcare workers is required to identify impairments to enable prompt interventions to be co-ordinated.

Can early subclinical gait changes in children with haemophilia be identified using the GAITRite�walkway

Development of haemophilic arthropathy has long-term implications for functional mobility in people with haemophilia, but early manifestations are often asymptomatic and difficult to identify. Earlier identification of joint damage may improve outcomes. The aim of this case note review was to determine whether the GAITRite system (electronic pressure sensitive walkway) could identify early changes in gait patterns in boys with haemophilia compared with their peers. Clinic data from medical and physiotherapy notes of boys with severe haemophilia were compared with data from age and leg length-matched controls. Data from two consecutive walks at preferred speed were collected on all participants using the GAITRite system. Clinic assessment notes from 26 boys (aged 7-17 years) with severe haemophilia were identified. Of these, 20 boys had no evidence of joint pathology on assessment and six boys had radiographic evidence of arthropathy. When these data were compared with normal controls, there were statistically significant increases in swing time, stance time, single support and double support in the asymptomatic group (P < 0.01) suggesting subtle early compensatory changes in gait pattern. The children with arthropathy had additional significant differences in their gait compared with matched controls. These differences included normalized velocity, step length, stride length, step time and base of support (P < 0.01). The GAITRite system appears sensitive enough to identify early subtle changes in gait and differentiate between asymptomatic boys with haemophilia and those with arthropathy in comparison with a matched control group. The electronic walkway is an accessible and portable means of providing quantitative gait analysis in the clinical environment. This is an important finding as early identification of gait changes may provide clinicians with the opportunity to intervene with the aim of arresting progression of joint damage.

Outpatient rehabilitative treatment of chronic fatigue syndrome (CFS/ME)

AIMS

To assess the outcome of outpatient multidisciplinary rehabilitative treatment (graded activities/exercise programme, family sessions, and supportive care) compared with supportive care alone for children and adolescents with chronic fatigue syndrome (CFS/ME).

METHODS

Fifty six young people (aged 9-17 years) with CFS/ME by standard criteria were followed up for 3-24 months. All subjects received supportive care. Families additionally opted to either enter the rehabilitation programme (supportive care plus graded activities/exercise programme and family sessions) or have no additional treatment.

RESULTS

Twenty two (39%) subjects had supportive care alone and 26 (46%) entered the programme. Treatment groups were comparable at baseline in terms of age, severity and duration of illness, Wellness score, and school attendance. At end of follow up, those in the programme group had significantly higher Wellness score and school attendance than those having supportive care alone. The programme significantly reduced the overall severity of illness: after the programme, 43% had complete resolution of CFS/ME compared to only 4.5% of those having supportive care alone. The presence of depressed mood and family beliefs about the aetiology of CFS/ME were not significantly associated with outcomes.

CONCLUSIONS

Outpatient rehabilitative treatment offers significant potential to improve the prognosis of CFS/ME in childhood and adolescence.