Upper-Body Exercises With External Resistance Are Well Tolerated and Enhance Muscle Activity in People With Hemophilia

Effects of resistance training on muscle strength in adults with haemophilia: A systematic review and meta-analysis

INTRODUCTION

Although resistance training is frequently prescribed for people with haemophilia (PWH), no previous meta-analyses have quantified the effect of this intervention on muscle strength, nor the implications of the intervention's modality and duration.

AIM

(1) To determine the effects of resistance training on muscle strength in adults with haemophilia; (2) To determine the most effective duration and modality among the exercise protocols.

METHODS

A systematic search from inception until 28 November 2023 was conducted in PubMed, Embase, Web of Science, CENTRAL and CINAHL databases. We included randomised controlled trials or before-after studies that involved resistance training without other physiotherapy co-interventions. Study selection, data extraction and risk of bias assessment were independently performed by two reviewers. Disagreements were resolved in consultation with a third author. The level of evidence was determined according to the GRADE methodology.

RESULTS

Seven studies were included. Measurements of knee extensor strength and elbow extensor strength were included in the meta-analysis. Subgroup analysis showed significant effects for both elastic resistance protocols (SMD: 0.54; 95% CI: 0.02-1.07) and conventional training (isometric and weight-based equipment) (SMD: 0.88; 95% CI: 0.50-1.25), demonstrating small and moderate effect sizes respectively. Additionally, both protocols of duration 5-7 weeks (SMD: 1.16, 95% CI: 0.63-1.69) as well as those of duration ≥8 weeks (SMD: 0.57, 95% CI: 0.20-0.94) showed a significant difference.

CONCLUSION

Resistance training is effective in improving muscle strength of the knee and elbow extensors in PWH. Both elastic resistance and conventional training show benefits.

The relationship between chronic pain and psychosocial aspects in patients with haemophilic arthropathy. A cross-sectional study

BACKGROUND

Pain is a major characteristic in haemophilic arthropathy. Identifying the psychosocial variables affected by pain can help when addressing these patients.

AIM

To assess the relationship between perceived intensity of chronic pain and joint damage, kinesiophobia, catastrophism, anxiety and perceived quality of life in adult patients with haemophilic arthropathy.

METHODS

Multicentre cross-sectional descriptive study. Seventy-seven adult patients with haemophilic arthropathy were recruited. The usual and maximum pain intensity (Visual Analog Scale), joint status (Haemophilia Joint Health Score), Kinesiophobia (Tampa Scale of Kinesiophobia), catastrophism (Pain catastrophizing scale), anxiety (State-Trait Anxiety inventory) and perceived quality of life (36-Item Short Form Health Survey) were evaluated. The correlation between usual and maximum pain intensity with quantitative variables was obtained with Spearman`s correlation test. Kruskal-Wallis one-way ANOVA analysed differences in perceived pain according to the severity and type of treatment, and development of inhibitors.

RESULTS

The usual intensity of perceived pain correlated positively with catastrophism, kinesiophobia, and state and trait anxiety. The same results were obtained when analysing the maximum perception of pain. We found an inverse correlation between the physical component of perceived quality of life and usual and maximum pain intensity perceived by patients.

CONCLUSION

Psychosocial factors affect the painful experience of patients with haemophilic arthropathy. Pain intensity affects the quality of life of these patients.

The effects of manual therapy on musculoskeletal system, functional level, joint health and kinesiophobia in young adults with severe haemophilia: A randomized pilot study

INTRODUCTION

The effects of manual therapy (MT) on joint health and functional level in haemophilic arthropathy (HA) have relatively under-explored.

AIM

To investigate the effects of MT in HA of lower limb joints on musculoskeletal system, functional level, Functional Independence Score in Hemophilia (FISH), Hemophilia Joint Health Score (HJHS) and kinesiophobia.

METHODS

Seventeen patients were randomized to the control group (CG = 9) and manual therapy group (MTG = 8). The number of haemarthrosis (NoH) was recorded from the diaries. Range of motion (ROM), strength and pain intensity were measured using goniometer, digital dynamometer and visual analogue scale, respectively. Joint health was evaluated with HJHS, functional independence with FISH, and kinesiophobia with Tampa Scale. Functional Reach (FR), Timed Up-Go (TUG) and 5-Times Sit-to-Stand (5*STS) tests were used to evaluate functional level. Home exercises were given to both groups. Additionally, myofascial release techniques and mobilizations were applied to MTG. Interventions were applied 3 d/weekly for 5 weeks. Assessments were performed at baseline and after treatment.

RESULTS

ROM, strength, activity pain, HJHS and FISH were improved in MTG (p˂0.05). Ankle NoH, 5*STS and FR were developed in both groups (p˂0.05), but kinesiophobia, TUG and knee NoH were not significant. Although improvements were observed in favour of MTG in HJHS, FR, activity pain and ankle strength/ROM (p˂0.05), no significant difference was found in FISH, kinesiophobia, TUG, 5*STS, resting pain and knee strength.

CONCLUSION

Reduction in ankle NoH indicated that both interventions were safe. The use of MT in HA of lower limb joints was an effective physiotherapy approach to improve functional level, joint health and functional independence.

Feasibility, safety and muscle activity during flywheel vs traditional strength training in adult patients with severe haemophilia

INTRODUCTION

Eccentric training has been associated with several specific physiological adaptations. The flywheel machine is one of the easiest ways of performing eccentric overload training. However, no studies evaluated its feasibility, safety and muscle activity in patients with haemophilia (PWH).

AIM

To evaluate feasibility and safety and compare muscle activity during flywheel vs weight machine knee extension exercise in severe PWH.

METHODS

Eleven severe PWH [mean age of 33.5 (8.1) years] participated in this cross-sectional study after receiving prophylactic treatment. Surface electromyography (EMG) signals were recorded for the rectus femoris during the knee extension exercise performed with 2 different conditions (flywheel and weight machine) with matched intensity (6 on the Borg CR10 scale). Kinesiophobia was assessed before and after the experimental session. Participants were asked to rate tolerability of each condition. Adverse effects were evaluated 24 and 48 hours after the session.

RESULTS

Kinesophobia did not increase after the experimental session, and no adverse effects were reported. At 60%-70% of the contraction cycle, the flywheel exercise showed higher (P = .024) eccentric rectus femoris muscle activity than the weight machine. In contrast, during the last 90%-100% of the contraction cycle, the traditional weight machine showed higher (P = .004) rectus femoris activity than the flywheel.

CONCLUSION

The knee extension exercise performed with the flywheel at moderate intensity is safe and well tolerated among severe PWH under adequate factor coverage. Importantly, the flywheel variation provides higher eccentric rectus femoris activity at the breaking force moment, while it provides lower eccentric muscle activity at the end of the cycle.

Safety and Effectiveness of Progressive Moderate-to-Vigorous Intensity Elastic Resistance Training on Physical Function and Pain in People With Hemophilia

OBJECTIVE

Strength training is recommended for people with hemophilia; however, published data are anecdotal and have methodological limitations. The purpose of this study was to evaluate the safety and effectiveness of progressive moderate-to-vigorous intensity elastic resistance training on physical function and pain in this patient population.

METHODS

A randomized controlled trial was conducted in a university laboratory setting where 20 patients (17 with severe, 1 with moderate, and 2 with mild hemophilia) aged 21 to 53 years received evaluations at baseline and 8-week follow-up. Participants were allocated to intervention (progressive strength training) or control (usual daily activities) groups. The intervention group trained 2 days per week during 8 weeks with elastic resistance. Intensity during the first 2 weeks was a 20-repetition maximum and increased progressively toward 15, 12, and finally 10 repetition maximum. The primary outcome was muscle strength. Secondary outcomes were the Timed "Up and Go" Test score, sit-to-stand, range of motion, Haemophilia Joint Health Score, kinesiophobia score, global impression of pain change, general self-rated health status, and desire to exercise.

RESULTS

The intervention group showed greater strength improvements than the control group in almost all of the joints, with moderate to high effect sizes. The intervention group also showed better Timed "Up and Go" and sit-to-stand scores than the control group (moderate effect size), greater range of motion at the knee flexion with the right leg (trivial effect size), and better Haemophilia Joint Health Score at the left knee (small effect size). The intervention group showed greater overall pain reduction, self-rated overall status, and desire to exercise than the control group.

CONCLUSIONS

Progressive strength training with elastic resistance performed twice a week during 8 weeks is safe and effective in people with hemophilia to improve muscle strength and functional capacity, reduce general pain, and improve self-rated health status and desire to exercise.

IMPACT

This study provides evidence for the use of a specific strength training regimen for people with hemophilia.

LAY SUMMARY

People with hemophilia of differing levels of severity, with adequate coverage with clotting factor, can safely engage in progressive strength training and can improve their functioning.

EMG, Rate of Perceived Exertion, Pain, Tolerability and Possible Adverse Effects of a Knee Extensor Exercise with Progressive Elastic Resistance in Patients with Severe Haemophilia

In people with haemophilia (PWH), elastic band training is considered an optimal option, even though the literature is scarce. The aim was to evaluate normalized electromyographic amplitude (nEMG), rate of perceived exertion (RPE), pain, tolerability, and possible adverse effects during the knee extension exercise using multiple elastic resistance intensities in PWH. During a single session, 14 severe PWH undergoing prophylactic treatment performed knee extensions without resistance and with different intensity levels of elastic resistance. nEMG was measured for the knee extensors and participants rated their RPE, tolerability and pain intensity after each condition. Patients had to report the possible adverse effects after the session. In most of the cases, an nEMG increase is only evidenced after increasing the resistance by two to three levels. Significant associations were found between RPE and the nEMG (ρ = 0.61), as well as between the elastic resistance level and nEMG (ρ = 0.69) and RPE (ρ = 0.71). All conditions were generally tolerated, without increased pain, and no adverse effects were reported. A wide variety of elastic resistance intensities during the knee extension are safe, tolerated, and do not increase knee pain in the majority of severe PWH undergoing prophylactic treatment.

The effect of resistance exercise on strength and safety outcome for people with haemophilia: A systematic review

Introduction

Haemophilia is a congenital bleeding disorder with severe musculoskeletal complications. Resistance exercise is important to increase joint stability and to improve physical performance.

Aim

This review aimed to investigate the safety and efficacy of resistance exercise interventions on people with haemophilia (PwH) and evaluate whether the American College of Sports Medicine resistance exercise criteria for healthy adults are valid for this population.

Methods

A systematic search in literature was conducted, using the databases PubMed, MEDLiNE, CINAHL, SCOPUS, PEDro and Cochrane Library. Out of 2.440 studies published between 1960 and November 2019, 14 studies (9 randomized controlled trials, 1 controlled trial, 4 single‐group prospective studies) applying resistance exercise in juvenile and adult PwH corresponded to the inclusion criteria.

Results

Studies performed dynamic, isokinetic or a combination of isometric and dynamic resistance training. Most interventions were carried out in the context of a multimodal training. Resistance was provided using fixed and free weights, body weight, resistance bands and water resistance. Study protocols included clinical and home‐based settings. Several studies suggest that training intensities lower than those known to increase the strength of healthy people are effective in increasing the strength of PwH. Resistance exercise seems to be a safe intervention if it is adequately monitored, individually adapted and applied with sufficient factor therapy. Due to the heterogeneity of study designs, training interventions and outcome measures a meta‐analysis could not be performed.

Conclusions

Further studies of higher methodological quality are needed to determine the optimal types of exercise, optimal dosage and timing.

Electromyographic and Safety Comparisons of Common Lower Limb Rehabilitation Exercises for People With Hemophilia

BACKGROUND

Ankles and knees are commonly affected in people with hemophilia and thus are targets for prevention or rehabilitation. However, to our knowledge, no studies have evaluated muscle activity and safety during exercises targeting the lower limbs in people with hemophilia; this lack of information hinders clinical decision-making.

OBJECTIVE

The aim of this study was to compare the tolerability of, safety of, and muscle activity levels obtained with external resistance (elastic or machine)-based and non-external resistance-based lower limb exercises in people with hemophilia.

DESIGN

This was a cross-sectional study.

METHODS

Eleven people who had severe hemophilia and were undergoing prophylactic treatment participated. In a single experimental session, participants performed knee extension and ankle plantar flexion during 3 exercise conditions in random order: elastic band-based resistance (elastic resistance), machine-based resistance (machine resistance), and no external resistance. Exercise intensities for the 2 external resistance-based conditions were matched for perceived exertion. Muscle activity was determined using surface electromyography (EMG) for the rectus femoris, biceps femoris, gastrocnemius lateralis, and tibialis anterior muscles. Participants were asked to rate exercise tolerability according to a scale ranging from "very well tolerated" to "not tolerated" and to report possible adverse effects 24 and 48 hours after the session.

RESULTS

No adverse effects were reported, and exercise tolerability was generally high. In the knee extension exercise, the rectus femoris normalized EMG values during the elastic resistance and machine resistance conditions were similar; 29% to 30% higher activity was obtained during these conditions than during the non-external resistance condition. In the ankle plantar flexion exercise, the gastrocnemius lateralis normalized EMG value was 34% higher during the machine resistance condition than without external resistance, and the normalized EMG values during the elastic resistance and other conditions were similar.

LIMITATIONS

The small sample size and single training session were the primary limitations of this study.

CONCLUSIONS

Exercises performed both with elastic bands and with machines at moderate intensity are safe, feasible, and efficient in people with severe hemophilia, providing comparable activity levels in the agonist muscles.