Effects of exercise in people with haemophilia: An umbrella review of systematic reviews and meta‐analyses

Acute neuromuscular and perceptual responses to blood flow restriction exercise in adults with severe haemophilia: A pilot study

INTRODUCTION

No previous studies have implemented a standard blood flow restriction (BFR) training session in people with severe haemophilia (PwH), where this type of training has been contraindicated.

AIMS

The purpose of this study was to evaluate the tolerability, adverse events, and neuromuscular and perceptual responses to an acute session of low load (LL) knee extensions with BFR in PwH under prophylaxis.

METHODS

Eight PwH performed one LL-BFR session with 40% arterial occlusion pressure (AOP). Perceptual responses and adverse effects were assessed, together with high-density surface electromyography of vastus medialis (VM) and lateralis (VL).

RESULTS

Significant normalized root mean square differences were found within each set, but not between sets. Spatial distribution (centroid displacement (p > .05), modified entropy (VM, set two, cycles three and five, p = .032) and coefficient of variation (VM, set two, cycles four and five lower than cycle three (p = .049; p = .036)) showed changes within each set. Median frequency showed a slight increase during cycle four of set four (p = .030). Rate of perceived exertion slightly increased with each set while tolerability slightly decreased in the last set and fear of training with BFR generally decreased after the session.

CONCLUSIONS

In PwH, a LL-BFR session at 40% AOP is safe and feasible. Our results suggest that potential muscle impairments may blunt neuromuscular adaptations induced by BFR.

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.

30-sit-to-stand power is a better tool than isometric knee extensor strength to detect motor impairment in people with haemophilic arthropathy

INTRODUCTION

Regular assessment of motor impairments is crucial in people with haemophilic arthropathy (PwHA). This study aimed to determine if there are differences in 30-seconds sit-to-stand (30-STS) power and maximal voluntary isometric contraction (MVIC) of the knee extensors between PwHA and healthy control group (CG). The secondary aims were to investigate the correlation between 30-STS power and MVIC of knee extensors with clinical characteristics and to assess their effectiveness in identifying motor impairment in PwHA.

METHODS

A cross-sectional study was conducted by collecting data from PwHA (n = 17) and a sedentary CG (n = 15). MVIC (torque) and 30-STS power were normalised to body mass. Correlation analysis and simple linear regression adjusted for age were used to assess the association between tests and clinical variables. Using z-scores derived from the mean and standard deviation of the CG, we compared the MVIC and the 30-STS power in PwHA.

RESULTS

PwHA showed lower MVIC and 30-STS power compared to CG (p < .001; large effect size d > .8). Lower 30-STS power was associated with greater joint impairment and greater fear of movement, whereas MVIC showed no association with clinical variables. 30-STS power showed a lower z-score compared to MVIC (p < .001). In addition, 30-STS power detected 47% of PwHA with motor impairment compared to 0% for MVIC (p = .002).

CONCLUSIONS

Our results suggest that 30-STS power may be more effective than knee extensors MVIC in detecting motor impairment in PwHA. Consequently, lower limb skeletal muscle power, rather than maximum knee extensor strength, appears to be more affected in PwHA.

Impact of Exercise Interventions on Sustained Brain Health Outcomes in Frail Older Individuals: A Comprehensive Review of Systematic Reviews

Several systematic review studies highlight exercise's positive impact on brain health outcomes for frail individuals. This study adopts a Comprehensive Review of reviews (CRs) approach to amalgamate data from existing reviews, focusing on exercise's influence on brain health outcomes in older frail and pre-frail adults. The methodology involves a thorough search of Portuguese, Spanish, and English-indexed databases (i.e., Ebsco Health, Scielo, ERIC, LILACS, Medline, Web of Science, SportDiscus) from 1990 to 2022, with the AMSTAR-2 tool assessing evidence robustness. The search terms "physical exercise", "elderly frail", and "systematic review" were employed. Results: Out of 12 systematically reviewed studies, four presented high-quality (with metanalyses), while eight exhibit critically low quality. Positive trends emerge in specific cognitive and neuromotor aspects, yet challenges persist in psychosocial domains, complex cognitive tasks, and ADL outcomes. This study yields reasonable and promising evidence regarding exercise's influence on quality of life and depression in frail older individuals. However, the impact on biochemical markers remains inconclusive, emphasizing the need for standardized methodologies. Conclusions: The findings highlight the importance of acknowledging methodological nuances for clinicians and policymakers when translating these results into impactful interventions for aging populations. This emphasizes the necessity for a comprehensive and customized approach to exercise interventions aimed at fostering the sustainability of overall well-being in older individuals, aligning with United Nations Sustainable Development Goal 3.

Effectiveness of progressive moderate-vigorous intensity elastic resistance training on quality of life and perceived functional abilities in people with hemophilia: Secondary analysis of a randomized controlled trial

INTRODUCTION AND AIM

Strength exercise training is advised for people with hemophilia (PWH); however, few studies have been published and have methodological limitations. The purpose of this study was to evaluate the effectiveness of progressive elastic resistance training on quality of life and perceived functional abilities in PWH.

METHODS

Participants were randomly allocated to the intervention (n = 10) or control (n = 10) group. The intervention group performed progressive moderate-vigorous elastic resistance training (2 days/week, a total of 8 weeks), focusing on the muscles of the knee, elbow, and ankle joints. The control group continued its usual daily activities for 8 weeks. Quality of life (A36 Hemofilia-QoL®) and perceived functional abilities (Haemophilia Activities List) were assessed at baseline and an 8-week follow-up.

RESULTS

The intervention group improved the quality-of-life dimension of joint damage perception in comparison to the control group (p = .015, large effect size). Regarding perceived functional abilities, the intervention group improved lying, sitting, kneeling, and standing (p = .006, small effect size), and complex lower extremities activities (i.e., walking short and long-distance, and up-down stairs) (p = .006, small effect size) compared to the control group. No other significant differences were observed.

CONCLUSIONS

Eight weeks of progressive moderate-vigorous elastic resistance training in PWH improve the quality-of-life dimension of joint damage perception and perceived functional abilities (lying/sitting/kneeling/standing, and complex lower extremities activities). Our results suggest a limited effect of the program on the other items of quality of life measured by the questionnaire as emotional functioning, mental health, and social relationships. Importantly, no serious adverse effects occurred.

Pain interferes with daily activities, emotions and sleep in adults with severe, moderate and mild haemophilia: A national cross-sectional survey

INTRODUCTION

Pain is a major issue in people with haemophilia (PwH). Few studies comprehensively assessed pain in PwH using a biopsychosocial framework and studies in mild PwH are lacking.

AIM

To assess pain prevalence, pain interference and their relationship with health-related quality of life (HR-QoL) in male adults with haemophilia.

METHODS

A survey was initiated by the Belgian national member organisation. Pain in the last 24 h, pain severity (BPI-PS) and pain interference (BPI-PI) scores were obtained with the Brief Pain Inventory short-form (BPI). HR-QoL was evaluated with the EQ-5D-3L, giving the health utility index (EQ-HUI). Associations between EQ-HUI, BPI-PS and BPI-PI were analysed using Pearson's correlation test. A multiple regression analysed the relationship between HR-QoL and BPI-PS, with age and haemophilia severity as confounding factors.

RESULTS

Within 185 respondents (97, 31 and 57 respectively severe, moderate and mild PwH), 67% (118/177) reported pain. In severe, moderate and mild PwH, respectively 86% (79/92), 71% (22/31) and 32% (17/54) reported pain. Median [IQR] BPI-PS, BPI-PI and EQ-HUI scores were respectively 1.5 [.0; 4.0], 1.6 [.0; 3.6] and .81 [.69; 1.00]. PwH reported pain interference with general activity (56% (99/176)), psychosocial factors such as mood (53% (93/175)), and sleep (51% (90/177)). Moderate correlations were found between EQ-HUI, BPI-PS and BPI-PI. After adjusting for age and haemophilia severity, BPI-PS explained 14% of HR-QoL variance.

CONCLUSIONS

Pain is a major issue amongst PwH, including people with mild haemophilia. Pain interferes with activities, emotions, sleep and HR-QoL, arguing for a comprehensive biopsychosocial approach of pain.

Proof of concept and feasibility of a blended physiotherapy intervention for persons with haemophilic arthropathy

BACKGROUND

Regular physiotherapy with a physiotherapist experienced in the field is not feasible for many patients with haemophilia. We, therefore, developed a blended physiotherapy intervention for persons with haemophilic arthropathy (HA) (e-Exercise HA), integrating face-to-face physiotherapy with a smartphone application.

AIM

The aim of the study was to determine proof of concept of e- Exercise HA and to evaluate feasibility.

METHODS

Proof of concept was evaluated by a single-case multiple baseline design. Physical activity (PA) was measured with an accelerometer during a baseline, intervention and post-intervention phase and analysed using visual inspection and a single case randomisation test. Changes in limitations in activities (Haemophilia Activities List [HAL]) and a General Perceived Effect (GPE) were evaluated between baseline (T0), post-intervention (T1) and 3 months post-intervention (T2) using Wilcoxson signed rank test. Feasibility was evaluated by the number of adverse events, attended sessions and open-ended questions.

RESULTS

Nine patients with HA (90% severe, median age 57.5 (quartiles 50.5-63.3) and median HJHS 32 (quartiles 22-36)) were included. PA increased in two patients. HAL increased mean 15 (SD 9) points (p = .001) at T1, and decrease to mean +8 points (SD 7) (p = .012) at T2 compared to T0. At T1 and T2 8/9 participants scored a GPE > 3. Median 5 (range 4-7) face-to-face sessions were attended and a median 8 out of 12 information modules were viewed. No intervention-related bleeds were reported.

CONCLUSION

A blended physiotherapy intervention is feasible for persons with HA and the first indication of the effectiveness of the intervention in decreasing limitations in activities was observed.

Effectiveness of myofascial therapy on hemophilic arthropathy: A systematic review and meta-analysis of clinical trials

Background

Recurrent hemarthrosis is one of the major complications affecting joint functions, and causing chronic pain in hemophilia patients.

Objective

To summarize the existing evidence of the effects of myofascial therapy (MFT) on joint status, joint pain, and hemarthrosis in hemophilic arthropathy.

Methods

This systematic review and meta-analysis was done according to PRISMA checklist. Finally, four clinical trials included and were pooled using STATA 13. Standardized mean difference (SMD) considered as the effect size.

Results

All patients in the case group received 3 interventions of MFT over a 3-week period and were evaluated for 1-5 months. Joint pain with and without load was significantly decreased after three weeks in the intervention group compared to controls (SMD: -0.61, 95% CI: -1.02, -0.21 and 0.58, 95% CI: -0.88, -0.28 respectively). Also, joint status significantly improved three weeks later in patients with MFT compared to controls. (SMD: -0.49, 95% CI: -0.79, -0.19) and this improvement remained until the end of the follow-up period (SMD: -0.54, 95% CI: -0.84, -0.24).

Conclusion

This meta-analysis showed that MFT can be an effective intervention improving the joint status and decreasing pain perception in patients with hemophilic arthropathy. Consequently, it can play an important role in achieving higher functionality and quality of life in these patients. However, due to the small number of studies and other limitations, further well-designed trials and updated meta-analysis are needed for more accurate results and interpretation.

The effects of close kinetic chain exercises on proprioception and physical activity level in pediatric patients with hemophilia

INTRODUCTION

Knee joint proprioception is affected, and lower extremity functioning declines over time in patients with hemophilia A.

AIM

To investigate the effects of a structured exercise programme consisting of the close kinetic chain (CKC) exercises on proprioception and physical activity level in pediatric patients with hemophilia.

METHODS

A total of 21 patients with hemophilia A who had at least one target knee joint were randomized into three groups: Study Group (SG, n = 7), Conventional Treatment Group (CTG, n = 7) and Control Group (CG, n = 7). The SG received a structured, lower limb-specific exercise protocol consisting of CKC exercises 2 days a week for 12 weeks, in addition to prophylactic treatment. The CTG received exercise training as described in the published literature. The CG continued to receive prophylactic treatment during the study period. Proprioception was measured using a digital goniometer before and after treatment in open and closed kinetic chain positions (CKCPs). The Five Times Sit to Stand (STS), Timed Up and Go (TUG) and Functional Independence Score in Hemophilia were used for the assessment of physical activity level.

RESULTS

A significant pre/post-treatment difference was found among the groups in proprioception (p = .001) and physical activity level (TUG p = .008, STS p = .001, FISH p = .006). Improvements in proprioception and physical activity level were greater in the SG compared to the other two groups (p < .05).

CONCLUSION

Compared to conventional exercise, the structured exercise protocol consisting of CKC exercise training produced improvements in proprioception and physical activity in patients with hemophilia A.

Effectiveness of physical exercise on postural balance in patients with haemophilia: A systematic review

INTRODUCTION

Balance training is important to improve balance and to decrease the risk of falls in patients with haemophilia (PWH).

AIM

To analyse the current knowledge about the effectiveness of physical exercise on postural balance in PWH.

METHODS

A systematic search for clinical trials, published before November 2021, was conducted using the following electronic databases: PubMed/MEDLINE, Web of Science, Embase, Wiley Online Library and the Cochrane Central Register of Controlled Trials (CENTRAL). Two independent reviewers extracted the data and assessed the risk of bias. The certainty of the evidence was analyzed using GRADE.

RESULTS

A total of ten studies involving 304 patients were included. The studies performed strength and balance exercises, and some included flexibility, mobilization, and/or aerobic exercises in their training programs. Postural balance was evaluated using a force platform and the one leg stand test was the most frequently used. Only five exercise programs achieved a significant increase in balance (pre-post) with a strength, postural balance, flexibility, and aerobic intervention. In general, the quality rate of the risk of bias was fair but the overall quality of the evidence across the studies was very low.

CONCLUSION

Five studies showed that there is a positive change in balance after the intervention. However, there is currently an unclear demonstration of evidence for the use of physical exercises to improve postural balance in people with haemophilia. Further studies with a higher methodological quality are needed.

Project GYM: A randomized feasibility study investigating effect on motivation of personal trainer-led exercise in young men with hemophilia

INTRODUCTION

Many young men with hemophilia engage in physical activity and sport but face challenges to participation because of their hemophilia. Project GYM aimed to investigate the feasibility of a hemophilia-specific fitness program led by a personal trainer (PT) and its impact on gym activity, motivation, and adherence to exercise.

METHODS

This was a nonblinded, randomized feasibility study, recruiting participants aged 18 to 25 years with hemophilia A or B (all severities, ± inhibitor) from three London hemophilia centers. All participants were given an activity tracker and free gym membership. Participants were randomized to a "gym only" or "gym and PT" arm. Participants completed questionnaires evaluating motivation to exercise, quality of life, physical activity levels, self-efficacy, and self-esteem at study start and study end.

RESULTS

Of 142 eligible individuals, 19 agreed to participate. Participants were healthy, with mean body mass index and adiposity slightly lower than the UK average. They reported low bleed numbers and had good joint health (median Hemophilia Joint Health Score [HJHS], 0; range, 0-13). The gym and PT group had more gym attendance than the gym-only group. Seven participants increased their activity levels and nine stayed the same, with no statistical difference between groups. HJHS scores improved in 3 participants and were unchanged in 12. There was no bleeding associated with gym activity.

CONCLUSION

Project GYM has demonstrated the safety and feasibility of a tailored physical training program in young men with hemophilia. Increased gym attendance, with and without support from a PT, is associated with increased physical activity.

Hemophilic arthropathy: a teaching approach devoted to hemophilia treaters in under-development countries

INTRODUCTION

Arthropathy is the characteristic injury of hemophilia, primarily occurring in the elbows, knees, and ankles. The aim of this review is a teaching approach devoted to hemophilia treaters in under-development countries.

AREAS COVERED

Current major challenges include the absence of the following therapeutic tools for all people with hemophilia (PWH) worldwide: hematological prophylaxis; well-coordinated multidisciplinary teams in specialized centers; joint aspiration of acute hemarthrosis; point-of-care ultrasonography (POC-US); exercise; treatment of synovitis by means of radiosynovectomy; treatment of mild hemophilic arthropathy with analgesics, anti-inflammatory agents, and rehabilitation medicine; intra-articular injections of corticosteroids, hyaluronic acid, platelet-rich plasma, and mesenchymal stem cells; and treatment of severe hemophilic arthropathy by surgical treatment. The future scenario in under-development countries should include all the aforementioned treatment tools plus the possibility of performing total joint arthroplasty in PWH with inhibitors; concomitant use of bypassing agents with emicizumab for PWH with inhibitors undergoing orthopedic surgery; and telemedicine.

EXPERT OPINION

Primary hematological prophylaxis is now the gold standard for the management of hemophilia. Acute hemarthrosis needs intense hematological management and articular aspiration; the articular situation should be scrutinized by POC-US. Synovitis can be controlled by radiosynovectomy. In cases of severe articular degeneration, surgical procedures might be required.

Effects of Exercise in the Treatment of Alzheimer's Disease: An Umbrella Review of Systematic Reviews and Meta-Analyses

The authors aimed to provide an overview of the evidence on the effects of exercise in people with Alzheimer's disease through a comprehensive review of the existing systematic reviews and meta-analyses. A literature search was performed in CINAHL, Cochrane Library, EMBASE, PubMed, SPORTDiscus, Scopus, and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The AMSTAR-2-Tool was used for the quality assessment. Twenty-three reviews fulfilled the criteria. Most of the reviews investigated the effects of aerobic exercise on Alzheimer's disease symptoms. The largest effects of exercise were seen in terms of improved cognition by multiple exercises. The majority of the reviews were rated as being of moderate quality and none were classified as having high quality. Exercise is an effective way to treat Alzheimer's disease symptoms and has a low incidence of related adverse events. As most reviews were evaluated as low-moderate quality, caution is needed in the interpretation of the results.

Pain management in people with hemophilia in childhood and young adulthood

Introduction: People with hemophilia (PWH) commonly experience acute and chronic musculoskeletal pain during childhood and young adulthood, but their treatment is often inadequate.Areas covered: From 1 September 2020 to 15 April 2021, authors performed a literature search in PubMed and the Cochrane Library using 'hemophilia AND pain' as keywords. Authors found 1082 articles, 51 of which were chosen because we considered them to be intimately connected with the topic of this report. Multimodal pain treatment, including multimodal analgesia, physical and rehabilitation medicine (PRM), and psychological therapies (imagery or relaxation, hypnosis), is currently the most recommended treatment for PWH. In acute hemarthrosis, in addition to hematologic treatment and joint aspiration, paracetamol/acetaminophen should be prescribed if the pain is mild, metamizole if the pain is moderate, and soft opioids (codeine or tramadol) if the pain is severe. In cases of chronic musculoskeletal pain due to hemophilic arthropathy, paracetamol/acetaminophen, COX-2 inhibitors, PRM, intra-articular injections of some drugs (corticosteroids, hyaluronic acid, platelet-rich plasma, mesenchymal stem cells), radiosynovectomy and behavioral therapies are advised.Expert opinion: Management of musculoskeletal pain in children and young adults with hemophilia should employ multimodal pain treatment (multimodal analgesia, PRM, and psychological strategies).

Applying World Health Organization 2020 guidelines on physical activity and sedentary behavior to people with hemophilia

Introduction: The new World Health Organization (WHO) guidelines on physical activity incorporate new concepts, such as sedentary behavior, recommendations for specific age groups and for people living with chronic conditions and disability. This could be extrapolated for the first time to people with hemophilia (PWH) within the framework in which these recommendations are applicable. The benefits of physical activity for PWH include physical, psychological and social benefits.Areas covered: This is a narrative review of the literature. We searched the MEDLINE and the Cochrane Library for WHO guidelines and articles related to physical activity in PWH. For all population groups, the benefits of performing exercise outweigh the possible harms. In PWH, there is a perceived increased risk of bleeding associated with physical activity. However, research suggests that this risk is associated with trauma during activity rather than intensity of physical activity, which offers the most health benefits.Expert opinion: Given the hematological, physical and functional conditions of PWH are highly variable, individualized counseling is needed based on age, therapeutic strategy, degree of arthropathy and level of disability. In this article, we analyze the applicability of the WHO recommendations to PWH, which is important to further promote healthy lifestyle motivation.

Effects of a non-pharmacological approach for chronic pain management in patients with haemophilia: efficacy of cognitive-behavioural therapy associated with physiotherapy

INTRODUCTION

More than half of adult patients with severe haemophilia (PWH) suffer pain daily, with chronic pain (CP) in more than 15% of cases, thereby reducing their quality of life (QoL). However, there are no evidence-based therapeutic guidelines for pain management.

AIM

To evaluate the effectiveness of a combined protocol based on psychology and physiotherapy in the improvement of CP self-efficacy in PWH with CP. Secondary outcomes are changes in QoL, emotional status, pain and kinesiophobia.

METHODS

In this prospective controlled trial study, recruited patients were allocated either to an experimental group (EG, n = 10) or to a control group (CG, n = 9). EG received interventions over four months: one cognitive-behavioural therapy (CBT) session per month and three home exercise sessions per week. Self-efficacy (Chronic Pain Self-Efficacy Scale), QoL (A36 Hemophilia-QoL), emotional status (Hospital Anxiety and Depression Scale and Rosenberg's Self-esteem Scale), pain (Visual Analogue Scale) and kinesiophobia (Tampa Scale for Kinesiophobia) were assessed at three time points (Week 0, Month 4 and Month 7). The intervention effects were determined with mixed 2-factor ANOVAs.

RESULTS

The EG showed a significant improvement (p < .05) in the control of symptoms and pain management scores on the Self-Efficacy Scale, QoL, self-esteem emotional status, pain and kinesiophobia. The intervention effects remained significant (p < .05) over time for pain management, QoL, pain and kinesiophobia.

CONCLUSION

The non-pharmacological treatment applied based on CBT and physiotherapy showed to be effective in improving CP self-efficacy, QoL and emotional status, while reducing pain and kinesiophobia in PWH with CP.