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Théron A, Maumus M, Biron-Andreani C, Sirvent N, Jorgensen C, Noël D. What is the rationale for mesenchymal stromal cells based therapies in the management of hemophilic arthropathies? Osteoarthritis Cartilage 2024; 32:634-642. [PMID: 38160743 DOI: 10.1016/j.joca.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/21/2023] [Accepted: 12/07/2023] [Indexed: 01/03/2024]
Abstract
Hemophilia A and B are rare X-linked genetic bleeding disorders due to a complete or partial deficiency in the coagulation factors VIII or IX, respectively. The main treatment for hemophilia is prophylactic and based on coagulation factor replacement therapies. These treatments have significantly reduced bleeding and improved the patients' quality of life. Nevertheless, repeated joint bleedings (hemarthroses), even subclinical hemarthroses, can lead to hemophilic arthropathy (HA). This disabling condition is characterized by chronic pain due to synovial inflammation, cartilage and bone destruction requiring ultimately joint replacement. HA resembles to rheumatoid arthritis because of synovitis but HA is considered as having similarities with osteoarthritis as illustrated by the migration of immune cells, production of inflammatory cytokines, synovial hypertrophy and cartilage damage. Various drugs have been evaluated for the management of HA with limited success. The objective of the review is to discuss new therapeutic approaches with a special focus on the studies that have investigated the potential of using mesenchymal stromal cells (MSCs) in the management of HA. A systematic review of the literature has been made. Most of the studies have focused on the interest of MSCs for the delivery of missing factors VIII or IX but in some studies, more insight on the effect of MSC injection on synovial inflammation or cartilage structure were provided and put in perspective for possible clinical applications.
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Affiliation(s)
- Alexandre Théron
- IRMB, University of Montpellier, INSERM, Montpellier, France; Resources and Competence Center for Hereditary Hemorrhagic Diseases, CHU Montpellier, Montpellier, France; Department of Pediatric Oncology and Hematology, CHU Montpellier, Montpellier, France
| | - Marie Maumus
- IRMB, University of Montpellier, INSERM, Montpellier, France
| | - Christine Biron-Andreani
- Resources and Competence Center for Hereditary Hemorrhagic Diseases, CHU Montpellier, Montpellier, France
| | - Nicolas Sirvent
- Department of Pediatric Oncology and Hematology, CHU Montpellier, Montpellier, France
| | - Christian Jorgensen
- IRMB, University of Montpellier, INSERM, Montpellier, France; Clinical Immunology and Osteoarticular Disease Therapeutic Unit, Department of Rheumatology, CHU Montpellier, Montpellier, France
| | - Danièle Noël
- IRMB, University of Montpellier, INSERM, Montpellier, France; Clinical Immunology and Osteoarticular Disease Therapeutic Unit, Department of Rheumatology, CHU Montpellier, Montpellier, France.
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Wang Z, Gu Y, Wang R, Xiang S, Jin Z, Tong P, Lv S, Liu X. Total hip and knee arthroplasty in HIV- and HCV-positive hemophilia patients: short term follow-up of 14 patients. BMC Musculoskelet Disord 2023; 24:946. [PMID: 38057748 DOI: 10.1186/s12891-023-07087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/30/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Haemophilic arthropathy (HA) is a common comorbidity of haemophilia. Some people with haemophilia (PWH) were human immunodeficiency virus (HIV)-positive. Arthroplasty is an effective treatment for end-stage HA. This study was carried out to report the effectiveness and satisfaction following total hip arthroplasty (THA) or total knee arthroplasty (TKA) in PWH with HIV. PATIENTS AND METHODS All patients with haemophilia and HIV undergoing THA or TKA in our centre from January 2015 to June 2020 were reviewed. All patients were followed for at least twenty-four months. The improvements in postoperative indicators were evaluated at the latest follow-up, including the Visual Analogue Scale (VAS) score, range of motion (ROM), and validated joint scores such as Knee Society Score (KSS; clinical and functional) and Harris Hip Score (HHS). The complications and satisfaction were analysed likewise. Those were utilized to weigh the risks and benefits of the procedure in the population. RESULTS Fourteen patients (7 hips and 14 knees) were included in the study. The follow-up of the THA cohort was 53.3 months (range, 27-82) and the TKA cohort was 50.1 months (range, 25-85), respectively. The average VAS score was ameliorated from 7.3 to 3.0 and 6.6 to 2.8 in the two groups (P < .001, respectively). Similarly, two cohorts (THA and TKA) showed statistically significant changes in the extension and flexion ROM between the preoperative and the latest follow-up (P < .05, P < .001, respectively). Besides, statistically significant differences between the preoperative and final follow-up values of HHS (from 41.6 to 82.3), clinical KSS (from 34.8 to 72.8), and functional KSS (from 42.9 to 73.2) were observed (P < .001, respectively). Notably, there were 4 complications noted among 21 arthroplasties performed, giving a 19.0% complication rate. Based on the satisfaction score, the majority of patients were optimistic about the arthroplasty. CONCLUSION Given these findings, THA or TKA of the PWH with HIV is a worthwhile procedure and can be performed by an experienced and collaborative multidisciplinary team in a tertiary centre with a good haemophilia care system.
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Affiliation(s)
- Zhengming Wang
- Shi's Center of Orthopedics and Traumatology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Yong Gu
- Translational Medical Innovation Center, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, Jiangsu, China
- Department of Orthopedics, Zhangjiagang TCM Hospital, Nanjing University of Chinese Medicine, Zhangjiagang, Jiangsu, China
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Rui Wang
- Guanghua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Sicheng Xiang
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Zhaokai Jin
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Peijian Tong
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Shuaijie Lv
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China.
| | - Xun Liu
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China.
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Rodriguez-Merchan EC. Past, present and future of orthopedic surgery in hemophilia: looking to a world without bleeding and arthropathy in the near future. Expert Rev Hematol 2022; 15:821-831. [PMID: 35930399 DOI: 10.1080/17474086.2022.2110063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The purpose of this article is to review the literature on orthopedic surgery in people with hemophilia (PWH), to better understand its past and present and attempt to predict the future. AREAS COVERED A Cochrane Library and PubMed (MEDLINE) search of studies related to orthopedic surgery in PWH was analyzed. A downward trend in orthopedic surgery in PWH has been observed. Patients on continuous prophylaxis are less likely to require orthopedic surgery. In patients with hemophilia, the risk of major bleeding remains high after total joint arthroplasty, even with factor replacement. Cases of acute compartment syndrome, pseudotumors and even limb amputations are still observed in PWH. EXPERT OPINION Orthopedic surgery for PWH should always be performed in specialized centers with multidisciplinary expertise in the correct management of hemophilia. It is paramount to perform an accurate preoperative coagulation screening before surgery. The availability of prophylaxis through replacement and the recent non-replacement therapy in the well-developed countries will diminish substantially or hopefully abolish completely the need for surgery in the treatment of PWH. Therefore, we are looking to a world without bleeding and arthropathy in the next future. Unfortunately, this is not true for the under-development countries.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Kleiboer B, Layer MA, Cafuir LA, Cuker A, Escobar M, Eyster ME, Kraut E, Leavitt AD, Lentz SR, Quon D, Ragni MV, Thornhill D, Wang M, Key NS, Buckner TW. Postoperative bleeding complications in patients with hemophilia undergoing major orthopedic surgery: A prospective multicenter observational study. J Thromb Haemost 2022; 20:857-865. [PMID: 35080347 PMCID: PMC8940712 DOI: 10.1111/jth.15654] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Persons with hemophilia (PWH) are at risk for chronic hemophilic arthropathy (HA). Joint replacement surgery may be used to relieve intractable pain and/or restore joint function. OBJECTIVES This multicenter, prospective, observational cohort study evaluated the rate of bleeding during the postoperative period after total hip (THA) or knee arthroplasty (TKA). PATIENTS/METHODS We included PWH of any severity ≥18 years of age who were undergoing THA or TKA. Clinical decisions were made at the discretion of the treating physician according to local standards of care. Clinical data were prospectively recorded. Major bleeding was defined as bleeding in a critical site, bleeding that resulted in either a 2 g/dl or greater decrease in hemoglobin during any 24-h period, or transfusion of two or more units of packed red blood cells. RESULTS One hundred thirty-one procedures (98 TKA and 33 THA) were performed, 39 (29.8%) of which were complicated by major bleeding, including 46% of THA and 25% of TKA. The risk of major bleeding was increased in THA compared to TKA (OR 2.50, p = .05), and by the presence of an inhibitor (OR 4.29, p = .04), increased BMI (OR 4.49 and 6.09 for overweight and obese, respectively, compared to normal BMI, each p < .01), and non-use of an antifibrinolytic medication (OR 3.00, p = .03). Neither continuous clotting factor infusion (versus bolus infusion) nor pharmacologic thromboprophylaxis were associated with bleeding risk. CONCLUSIONS The bleeding risk remains substantial after THA and TKA in PWH, despite factor replacement. Use of antifibrinolytic medications is associated with decreased risk.
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Affiliation(s)
- Brendan Kleiboer
- Department of Medicine and UNC Blood Research Center, University of North Carolina
| | - Marcus A. Layer
- Department of Medicine and UNC Blood Research Center, University of North Carolina
| | | | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Miguel Escobar
- McGovern Medical School, University of Texas Health Science Center at Houston
| | | | - Eric Kraut
- The Ohio State University Hemostasis and Thrombosis Center
| | - Andrew D. Leavitt
- Department of Laboratory Medicine and Department of Internal Medicine, University of California San Francisco
| | - Steven R. Lentz
- Department of Internal Medicine, University of Iowa Carver College of Medicine
| | - Doris Quon
- Orthopaedic Hemophilia Treatment Center, Orthopaedic Institute for Children
| | - Margaret V. Ragni
- Department of Medicine and Clinical and Translational Science, University of Pittsburgh School of Medicine
| | | | | | - Nigel S. Key
- Department of Medicine and UNC Blood Research Center, University of North Carolina
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Rodriguez-Merchan EC, Encinas-Ullan CA, Gomez-Cardero P. Effectiveness of ankle fusion in patients with hemophilia, advanced ankle degeneration, and unbearable pain for whom nonsurgical and surgical treatments have been ineffective. Expert Rev Hematol 2021; 14:517-524. [PMID: 34042014 DOI: 10.1080/17474086.2021.1935850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: In underdeveloped countries, patients with hemophilia often experience repetitive ankle joint hemorrhages due to a shortage of coagulation factors (factor VIII [FVIII] and factor IX [FIX] for hemophilia A and B, respectively).Areas covered: This is a narrative literature review in which we searched the Cochrane Library and PubMed for articles related to ankle arthrodesis in patients with hemophilia. The searches covered the period from the databases´ inception to 28 February 2021. In the event of unsuccessful hematologic prophylaxis and conservative measures (e.g. analgesics, cyclooxygenase-2 inhibitors, taping, intra-articular injections of hyaluronic acid and corticosteroids, physical and rehabilitation medicine, orthoses, radiosynovectomy, and joint-preserving surgery (e.g. removal of the distal tibia by open surgery or by arthroscopic surgery, joint debridement by arthroscopic surgery), the classical surgical solution is ankle arthrodesis, which does not preserve the ankle joint.Expert opinion: Ankle pain is reduced after ankle arthrodesis (75% of patients experience no pain). Approximately 5% of patients require reoperation due to lack of fusion, and deep infection occurs in 2.5%. After tibiotalar fusion, a self-reported activity scale shows that approximately 12% of patients improve, 9% worsen, and 79% show no improvement. The results of ankle arthrodesis therefore appear to be poor.Therefore, although 75% of the patients stopped having ankle pain after arthrodesis, according to a self-reported activity scale 88% of them did not improve or worsened.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Rodriguez-Merchan EC. Management of musculoskeletal complications in patients with hemophilia: literature review and expert recommendations. Cardiovasc Hematol Disord Drug Targets 2021; 21:162-166. [PMID: 33906595 DOI: 10.2174/1871529x21666210427134232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/02/2021] [Accepted: 03/01/2021] [Indexed: 11/22/2022]
Abstract
In people with hemophilia, hematological prophylaxis during childhood and adolescence could elude the occurrence of musculoskeletal complications (in joints and muscles) if the concentration of the defective factor is averted from decreasing under 1% of normal. Prompt management is of capital significance as the juvenile skeleton is hypersensitive to the adverse events of the disease; intense structural defects might appear rapidly. Important articular bleeds and inveterate hypertrophy of the articular synovial membrane must be treated vigorously to preclude joint degeneration (hemophilic arthropathy). At the moment that extreme joint disease is in place with intense affliction, the goal must be to reestablish activity whilst at the same time reducing the peril to the patient. Articular debridement is an efficacious surgical technique to accomplish this goal, particularly around the knee or ankle, and may be contemplated to be a backup to ankle arthrodesis or ankle or knee replacement in patients of younger age. Eventually joint replacement can commonly reestablish both articular mobility and function in an unhealthy articulation.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid. Spain
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Rodríguez-Merchán EC. Recent advances in surgery and its perioperative treatment in people with hemophilia. Expert Rev Hematol 2021; 14:271-280. [PMID: 33605827 DOI: 10.1080/17474086.2021.1893689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: People with hemophilia (PWH) may require some surgical procedures (orthopedic surgery, cardiac surgery, neurosurgery, et cetera) throughout their lives.Areas covered: Articles on surgery and hemophilia published during the year 2020 were analyzed. The principal inclusion factor was a focal point on surgery in hemophilia. Articles that did not concentrate on this subject were not included.Expert opinion: Turoctocog alfa pegol appears to be efficacious for perioperative hemostatic treatment of all kind of surgical operations (minor and major) in PWH A. Long-acting recombinant coagulation factor IX (FIX) albumin fusion protein (rIX-FP) seems to facilitate perioperative management in PWH B. In people suffering from von Willebrand disease (VWD), the utilization of concentrates of von Willebrand factor (VWF) is commonly used for the decrease of exaggerated bleeding during surgical operations. On-demand management with 30-60 IU/kg may keep hemostasis under control during all kind of surgical operations. Factor concentrates with extended half-life (EHL) are a good option to standard half-life (SHL) products in PWH undergoing surgery, permitting diminished number of infusions and inferior consuming, particularly for EHL factor IX (FIX). Supplementary factor VIII (FVIII) and/or bypassing management have demonstrated to be secure and efficacious in association with emicizumab for major surgical procedures.
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Affiliation(s)
- E Carlos Rodríguez-Merchán
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Rodriguez-Merchan EC, De la Corte-Rodriguez H. Complications of hemophilia in the elbow: current management. Expert Rev Hematol 2020; 13:991-1001. [PMID: 32723183 DOI: 10.1080/17474086.2020.1803061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION After the ankle and knee, the elbow is the most commonly impaired joint in patients with hemophilia. AREAS COVERED A Cochrane Library and PubMed (MEDLINE) search related to elbow problems in hemophilia was conducted. Early and continuous primary hematological prophylaxis (ideally starting in infancy) is essential, given that the juvenile elbow is highly prone to the musculoskeletal complications of hemophilia. If primary hematological prophylaxis is not administered (due either to lack of affordability or lack of venous access), persistent hemarthrosis can occur in the elbow. Hemarthroses will then require aggressive treatment (through arthrocentesis under factor factor coverage) to prevent progression to synovitis (requiring prompt radiosynovectomy or arthroscopic synovectomy) and ultimately hemophilic arthropathy (requiring rehabilitation and orthopedic surgery). Between the second and fourth decade of life, many patients with hemophilia present elbow joint destruction. EXPERT OPINION In the initial stage of joint destruction, rehabilitation and intraarticular injections of hyaluronic acid can relieve the symptoms. In the advanced stage of hemophilic arthropathy, however, surgery is necessary. The main surgical procedures currently available are arthroscopic debridement, radial head resection, and total elbow arthroplasty. Transposition of the ulnar nerve and removal of heterotopic ossifications might also be necessary.
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Sharma Poudyal B, Marahatta S, Solimeno L, Forsyth A, Tuladhar S, Prajapati V, Rayamajhi S, Poudel B, Bajrachrya M, Neupane S, Rayamajhi A, Rc DR, Kouides P. Arthroplasty in haemophilia: Double-edged sword in low/middle-income countries. Haemophilia 2020; 26:e344-e345. [PMID: 32767450 DOI: 10.1111/hae.14124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Bishesh Sharma Poudyal
- Clinical Hematology and Bone Marrow Transplant Unit, Civil Service Hospital, Kathmandu, Nepal
| | - Suman Marahatta
- Department of Orthopedics, Civil Service Hospital, Kathmandu, Nepal
| | - Luigi Solimeno
- Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Traumatology and Orthopaedic Unit, Milan, Italy
| | - Angela Forsyth
- REBUILD Program Director, Diplomat Specialty Infusion Group: An affiliate of Optum, Flint, MI, USA
| | | | - Vimal Prajapati
- Department of Physiotherapy, Civil Service Hospital, Kathmandu, Nepal
| | - Sachita Rayamajhi
- Department of Physiotherapy, Civil Service Hospital, Kathmandu, Nepal
| | - Bishal Poudel
- Clinical Hematology and Bone Marrow Transplant Unit, Civil Service Hospital, Kathmandu, Nepal
| | - Malika Bajrachrya
- Clinical Hematology and Bone Marrow Transplant Unit, Civil Service Hospital, Kathmandu, Nepal
| | - Samir Neupane
- Department of Pathology, Civil Service Hospital, Kathmandu, Nepal
| | - Anuj Rayamajhi
- Department of Anesthesia, Civil Service Hospital, Kathmandu, Nepal
| | - Dirgha Raj Rc
- Department of Orthopedics, Civil Service Hospital, Kathmandu, Nepal
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, Rochester, NY, USA
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Krüger S, Hilberg T. Understanding the pain profile in patients with haemophilia: Impaired descending pain inhibition as measured by conditioned pain modulation. Haemophilia 2020; 26:236-242. [PMID: 32030862 DOI: 10.1111/hae.13939] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Haemophilic arthropathy is associated with pain that often becomes chronic, likely caused by peripheral and central mechanisms. In the field of haemophilia, to our knowledge, the role of the descending pain pathway, which can also be involved in these pain processes, has not been examined to date. AIM In light of the dearth of existing literature, we sought to evaluate the function of endogenous descending pain modulation in patients with haemophilia. METHODS Thirty adult patients with moderate to severe haemophilia A or B (median [interquartile range] age 51.0 [42.0-54.0]) and 23 healthy adult controls (age 46.5 [36.8-54.3]) underwent conditioned pain modulation (CPM) in order to examine the function of endogenous pain modulation. The CPM response was determined by scoring a test stimulus (heat) alone as well as under the influence of a conditioning stimulus (cold) on the basis of a numeric rating scale (NRS) (0 = 'no pain' to 100 = 'worst possible pain'). RESULTS Patients with haemophilia demonstrated a statistically significant reduced CPM response when compared with the age-matched healthy controls (median (interquartile range) NRS score: patients: -10 (-17.5-[-7.5]) vs controls: -20 (-30.0-[-13.75]); P = .002). The determined difference in the CPM response between both cohorts showed a medium effect size of r = .433. CONCLUSION The results of this study indicate that an impaired degree of endogenous pain modulation could be present in patients with haemophilia. Therefore, the function of the descending pain pathway should be considered regarding an individual and comprehensive pain management.
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Affiliation(s)
- Steffen Krüger
- Department of Sports Medicine, University of Wuppertal, Wuppertal, Germany
| | - Thomas Hilberg
- Department of Sports Medicine, University of Wuppertal, Wuppertal, Germany
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