A study to evaluate the effectiveness of 'Air-Stirrup' splints as a means of reducing the frequency of ankle haemarthroses in children with haemophilia A and B

A systematic review and narrative synthesis of footwear and orthotic devices used in the management of ankle haemarthrosis and haemarthropathy in haemophilia

Introduction

Haemarthrosis is a clinical feature of haemophilia leading to haemarthropathy. The ankle joint is most commonly affected, resulting in significant pain, disability and a reduction in health‐related quality of life. Footwear and orthotic devices are effective in other diseases that affect the foot and ankle, such as rheumatoid arthritis, but little is known about their effect in haemophilia.

Aims

To review the efficacy and effectiveness of footwear and orthotic devices in the management of ankle joint haemarthrosis and haemarthropathy in haemophilia.

Methods

A systematic literature review was conducted. Two review authors independently screened studies for inclusion and appraised methodological quality using Joanna Briggs Institute Critical Appraisal checklists. A narrative analysis was undertaken.

Results

Ten studies involving 271 male participants were eligible for inclusion. All studies were quasi‐experimental; three employed a within‐subject design. Two studies included an independent comparison or control group. A range of footwear and orthotic devices were investigated. Limited evidence from non‐randomised studies suggested that footwear and orthotic devices improve the number of ankle joint bleeding episodes, gait parameters and patient‐reported pain.

Conclusion

This review demonstrates a lack of robust evidence regarding the efficacy and effectiveness of footwear and orthotic devices in the management of ankle joint haemarthrosis and haemarthropathy in haemophilia. Methodological heterogeneities and limitations with the study designs, small sample sizes and limited follow‐up of participants exist. Future studies utilising randomised designs, larger sample sizes, long‐term follow‐up and validated patient‐reported outcome measures are needed to inform the clinical management of ankle joint haemarthrosis and haemarthropathy.

Recent advances in musculoskeletal physiotherapy for haemophilia

Physiotherapy is directed towards the movement needs and potential of individuals, providing treatment and rehabilitation to develop, maintain and restore maximum movement and functional ability throughout the lifespan. Recent systematic reviews and randomized controlled trials have extended evidence for the clinical efficacy of physiotherapy interventions and rehabilitation for people with haemophilia. This narrative review synthesizes recent evidence to discuss; differentiating musculoskeletal bleeding and haemophilic arthropathy, efficacy of physiotherapy and rehabilitation for acute musculoskeletal bleeding and arthropathy, as well as monitoring musculoskeletal health. Whilst robust evidence is emerging, there is a need for more well designed randomized clinical studies with larger numbers and homogeneity of participants and collaboration of all researchers and clinicians to identify a core set of outcome measures that can be used to monitor musculoskeletal health.

Computerized pedobarography in the characterization of ankle-foot instabilities of haemophilic patients

Among the most common clinical manifestations of haemophilia are joint haemorrhages. This study aimed to verify whether repetitive ankle haemarthrosis is associated with instability of the rear foot. We evaluated haemophilic patients with repetitive bleeding in the ankles, 39 of type A and four of type B, whose mean age was 16.1 years. All presented a functional gait, without the need for motion assistance devices. The number of rear-foot and ankle haemarthrosis episodes during the 6 months prior to the study was verified from the medical records of each patient. After verifying the alignment of the rear foot of the patients, we evaluated the subjects through computerized pedobarography with the f-scan system, emphasizing the study of the trajectory of the centre of pressure (COP) with each step taken. All patients received functional orthoses according to the results of these examinations, and were re-evaluated 1 week and 6 months after being fitted. The number of haemarthrosis episodes at the rear foot and the ankle was compared with the occurrence of joint bleeding within the previous 6 months. In the first examination, the COP trajectory showed that all the 43 patients studied had some sort of instability. Six months later, a significant reduction in the frequency of spontaneous bleeding events (P<0.001) concerning the rear foot and the ankle was observed. This method of evaluation was useful to identify joint instabilities, allowing the best prescription of orthoses to improve stability in the rear foot and the ankle.

The target joint

Bleeding into the joints is the most common manifestation of severe haemophiliacs. Although it may resolve spontaneously or with treatment, some patients find that one particular joint has recurrent bleeding; this is termed a target joint. Recurrent bleeding prevents the joint from regaining its range of motion, muscle strength and normal appearance. These changes become permanent, leading eventually to osteoarthritis. A target joint requires urgent and comprehensive treatment, especially in young patients, if permanent damage is to be prevented. Treatment with factor concentrate prophylaxis and physiotherapy can help to prevent new bleeds and allow the synovitis to resolve, but for persistent synovitis, synovectomy is recommended. The target ankle joint is a special challenge as it often develops in very young children when the articular cartilage is susceptible and compliance with conservative treatment is difficult.

Orthoses in haemophilia

In haemophilia patients, orthoses are used for the prevention and management of bleeds and their effects on the musculoskeletal system. The characteristics of these devices vary according to the joint to which they are applied, although two basic types are distinguished: static and functional. The upper limbs make up a functional unit that is adapted to prehension, or the action of grasping or seizing objects. The most affected joints of this unit in haemophilia are the elbow and shoulder, which require immobilization, followed by stabilization and protection and in the case of disability, assistance in the performance of function. The lower limbs, on the other hand, are adapted to the action of ambulation. The knee, ankle and hip joints frequently sustain damage in haemophilia, and in the acute phase they should be immobilized and the patient discouraged from walking. Once bleeding has ceased, and motion and muscle balance improved, a gradual return to normal activity may commence. The principle aim of orthotics in these cases is to immobilize and unburden the affected body segment, and to provide stability and assistance for ambulation. Shoe insoles cushion and modify stance, and therefore may help prevent lesions. Crutches and walking frames are used for restoring normal gait. Orthotic devices improve the quality of life of haemophilia patients with musculoskeletal lesions and are useful for preventing lesions resulting from strenuous activities, whether performed in the course of daily living or in the pursuit of games and sports.

Proprioceptive training in haemophilia

Joint and muscle injury associated with direct damage to the tissues and muscle atrophy may ensue following immobility. Rehabilitation of the injury is linked with the return to normal functional values such as range of motion, muscle strength, and muscle tone. It is, however, likely that subtle changes or differences still exist in the site of injury or haemarthrosis. In particular proprioception may be distorted due to the direct injury of sensory receptors and to feedback systems. The implications of such damage are important, where proprioception plays an important part in the control, timing and organisation of coordinated bodily actions.

Hemophilic ankle arthropathy

Ankle arthropathy remains a frequent source of disability in the hemophilic patient. Bleeding into the ankle most commonly commences in the second decade, and, once established as a target joint, progressive damage leads to significant pain, stiffness, and deformity affecting general mobility and leisure and occupational pursuits. Review of cohorts of hemophilic patients at the Royal Free Hospital has monitored this deterioration and there is no evidence that, despite improvements in medical treatment, the pattern of insidious decline in hindfoot function has changed during the past 4 decades. Based on these observations, a combined clinical and radiologic scoring system has been developed, incorporating ankle specific features, such as talar tilt, tibial osteophytes, and talar dome flattening, which give a better correlation than traditional systems with objective measures, such as treadmill walking. There is no substitution for prophylactic treatment in arresting ankle function decline, and surgical interventions are rare. However, the types of potential procedures are numerous and choices must be made according to the degree of disability and state of overall damage to the joint and adjacent soft tissues.