Enhancing lifestyle for individuals with haemophilia through physical activity and exercise: the role of physiotherapy

Using reference equations to standardise incremental shuttle walk test performance in children and young people with chronic conditions and facilitate the evaluation of exercise capacity and disease severity

AIMS

The aim was to evaluate whether standardised exercise performance during the incremental shuttle walk test (ISWT) can be used to assess disease severity in children and young people (CYP) with chronic conditions, through (1) identifying the most appropriate paediatric normative reference equation for the ISWT, (2) assessing how well CYP with haemophilia and cystic fibrosis (CF) perform against the values predicted by the best fit reference equation and (3) evaluating the association between standardised ISWT performance and disease severity.

METHODS

A cross-sectional analysis was carried out using existing data from two independent studies (2018-2019) at paediatric hospitals in London,UK. CYP with haemophilia (n=35) and CF (n=134) aged 5-18 years were included. Published reference equations for standardising ISWT were evaluated through a comparison of populations, and Bland-Altman analysis was used to assess the level of agreement between distances predicted by each equation. Associations between ISWT and disease severity were assessed with linear regression.

RESULTS

Three relevant reference equations were identified for the ISWT that standardised performance based on age, sex and body mass index (Vardhan, Lanza, Pinho). A systematic proportional bias of standardised ISWT was observed in all equations, most pronounced with Vardhan and Lanza; the male Pinho equation was identified as most appropriate. On average, CYP with CF and haemophilia performed worse than predicted by the Pihno equation, although the range was wide. Standardised ISWT, and not ISWT distance alone, was significantly associated with forced expiratory volume in 1 s in CYP with CF. Standardised ISWT in CYP with haemophilia was slightly associated with haemophilia joint health score, but this was not significant.

CONCLUSIONS

ISWT performance may be useful in a clinic to identify those with worsening disease, but only when performance is standardised against a healthy reference population. The development of validated global reference equations is necessary for more robust assessment.

The evolution of physiotherapy in the multidisciplinary management of persons with haemophilia (PWH): A scoping review

INTRODUCTION

Haemophilia is a rare congenital bleeding disorder, and the most common manifestation is spontaneous bleeding in muscles and joints. Despite the benefits linked to recent and dramatic pharmacological advances at least in high income setting, many patients still develop musculoskeletal dysfunctions during their lifetime, which must be managed by physiotherapists in the frame of a multidisciplinary team. The aim of the scoping review is to map the available evidence by providing an overview on the past and present physiotherapy scenario in persons with haemophilia (PWH).

MATERIALS AND METHODS

The review was conducted according to the guidelines of the PRISMA extension for scoping reviews. Scientific articles on physiotherapy and sport interventions for PWH published from 1960 up to September 2021 have been included. Search was conducted on the e-databases PubMed and PEDro without restrictions for the study design.

RESULTS

Sixty eight articles were included, 52 related to rehabilitation and preventive physiotherapy, 16 to sport. The results have been reported in chronological order and divided into two categories: (1) rehabilitation and preventive physiotherapy; (2) sport activities.

CONCLUSIONS

This is the first scoping review on physiotherapy in haemophilia, based on the existing evidence on this topic which allowed us to underline how the role of the physiotherapist changed over time. Historically this specialist did intervene only after an acute bleed or surgical operation, but now he has a pivotal role in the multidisciplinary team that acts to improve from birth the quality of life of the PWH. His activity is also closely intertwined with sport promotion and supervision.

Promoting physical activity in people with haemophilia: the MEMO (Movement for persons with haEMOphilia) expert consensus project

Regular physical activity can increase joint stability and function, reduce the risk of injury, and improve quality of life of people with haemophilia (PwH). However, a recent review of the literature shows that appropriate physical activity and sport are not always promoted enough in the overall management of PwH. A group of Italian experts in haemophilia care undertook a consensus procedure to provide practical guidance on when and how to recommend physical exercise programmes to PwH in clinical practice. Three main topics were identified -haemophilia and its impact on movement, physical activity recommendations for PwH, and choice and management of sports activity in PwH- and ten statements were formulated. A modified Delphi approach was used to reach a consensus. The group also created practical tools proposing different physical activities and frequencies for different age groups, the Movement Pyramids, to be shared and discussed with patients and caregivers. In conclusion, in the opinion of the working group, physical activity can be considered as a low-price intervention that can prevent/reduce the occurrence of chronic diseases and should be further encouraged in PwH to obtain multiple physical and psychological benefits. Future research should include prospective studies focusing on participation in sports, specific risk exposure and clinical outcomes.

Benefits of physical therapy for people living with hemophilia

This crossover study investigated effects of physical therapy (PT) on motor function in patients with hemophilia infected with human immunodeficiency virus (HIV) due to treatment with non-heat-treated blood products. Patients were randomly divided into a PT-first group (PT once monthly for 6 months, then only home exercise (HE) for 6 months) and an HE-first group (HE for 6 months, then PT once monthly for 6 months). Carryover, period, and treatment effects were examined. Carryover effect was observed for flexion muscle strength of the right hip joint and fast walking cadence. Period effect was observed for extension Range of motion (ROM) of the left hip joint, dorsiflexion of the right ankle joint, and fast walking cadence. PT tended to be effective for abduction of the left shoulder joint and fast walking cadence. Compared with HE, PT tended to contribute to improving ROM of the shoulder joints and fast walking.

Lower physical activity and altered body composition in patients with haemophilia compared with healthy controls

Introduction

Patients with haemophilia (PWH) have traditionally been discouraged from engaging in sports and strenuous exercise activities, due to the perceived risk of bleeding complications. This puts PWH at an increased risk to become overweight or obese. However, the benefits of many forms of physical activity seem to outweigh their risks, although activities with significant trauma risk should be avoided.

Aim

To evaluate physical activity patterns and body composition of adult PWH.

Methods

This cross‐sectional study compared data on physical activity from tri‐axial accelerometers and body composition of 18 male adult PWH (aged 18–49 years) on prophylactic replacement therapy and without acute joint bleedings to those of 24 healthy age‐matched controls, by means of Mann‐Whitney‐U‐Tests.

Results

Median moderate‐to‐vigorous physical activity was significantly (p = .000) lower in PWH (34.6 min/day) than in healthy controls (65.2 min/day). Body mass index was almost similar between PWH and controls (25.1 vs 24.2 kg/m², p = .431). Yet, we found a consistent trend towards less desirable outcomes across body composition parameters, such as median body fat rate (23.5 vs 17.0%, p = .055) in PWH, compared with controls.

Conclusion

Although physical activity has been recommended for PWH since the mid‐1970s, the physical activity engagement of adult PWH was still severely limited, possibly due to over‐cautiousness but presumably also in consequence of chronic pain. Poor physical activity engagement may well be expected to contribute to the increased body fat and decreased leg muscle mass. Consequently, policies should focus on improving the knowledge and motivation of PWH to engage in health‐enhancing physical activity.

Establishing an online physical exercise program for people with hemophilia

BACKGROUND

Hemophilia is a congenital bleeding disorder with an estimated frequency of 1:10,000 births. Repeated joint bleeding is a hallmark of the disorder and leads to painful hemophilic arthropathy. Regular exercise can help improve joint stability and function, reduce the risk of injury and bleeding and improve physical fitness and quality of life. This method paper describes an online training concept aiming to offer access to appropriate exercise instructions for people with hemophilia who are not able to attend regular training at a hemophilia center.

METHODS

The online exercise program is accessible through the homepage of the Department of Physical Medicine, Rehabilitation and Occupational Medicine of the Medical University Vienna as well as through scanning a QR code printed on information material using a smart phone or tablet.

RESULTS

The program contains exercises to improve mobility, coordination, muscular strength and flexibility. A brief introduction is given by a hematologist, a pediatrician and a physiatrist. An introductory video informs about contraindications and essential precautions, such as medical attendance and sufficient factor therapy to consider before starting the training. Another video gives advice on the exercise composition. The demonstrated exercises are explained by a physician and are available for adults and children. To individualize training recommendations and offer further diagnostic tools and physical treatment options as necessary, the Department of Physical Medicine, Rehabilitation and Occupational Medicine of the Medical University of Vienna will establish consultation hours for people with hemophilia.

CONCLUSION

As hemophilia is an orphan disease, patients are mainly treated in specialized centers. For patients who live far from these centers or have limited access to a training there for other reasons, the physical medicine consultation hour and the implementation of online exercise instructions offer individually adapted exercise information for a regular home-based training to benefit from increased physical fitness and joint stability.

Physical activity and its related factors in Japanese people with haemophilia

INTRODUCTION

In the general population, benefits of physical activity (PA) include improvement of physical function, prevention of lifestyle diseases and improvement of bone mineral content and quality of life. PA is recommended for patients with haemophilia (PwH), especially for those receiving advanced haemostatic treatment. We hypothesised many PwH engage in insufficient PA.

AIM

This study aimed to clarify PA levels and the associated factors in Japanese PwH.

METHODS

Physical activity was assessed using the International Physical Activity Questionnaire short version, and basic data, activities of daily living (ADLs) and self-efficacy were also collected.

RESULTS

A total of 106 questionnaires were completed. The average age of participant was 40.8 years. The median PA was 693.0 metabolic equivalent-min/wk. More than half of the participants (59.4%) were classified into the low activity group. PA showed a significant inverse correlation with age (P = 0.022) and a positive correlation with self-efficacy (P = 0.018). However, PA did not show a significant relationship with haemophilic severity, prophylactic treatment, annual intra-articular bleeding frequency, body mass index and ADL. In PwH receiving guidance in sports, such as activities that are safe to participate in or performing prophylaxis prior to a physical activity, self-efficacy was significantly higher (P = 0.033), ADL was better (P < 0.001), and mean age was younger (P = 0.01) than in those not receiving guidance in sports.

CONCLUSION

As for PA level, 60% of the subjects showed low activity. To promote PA in PwH, improvement of self-efficacy and appropriate guidance may be necessary.

Physiotherapy Treatments in Musculoskeletal Pathologies Associated with Haemophilia

The aim of this study is to offer physiotherapists a synthesis of the main therapeutic tools available for the treatment of musculoskeletal pathologies in patients with haemophilia, according to the scientific literature. Although bleeds are recognised as no longer being a cause of death for people with haemophilia, the accompanying musculoskeletal injuries now represent the main problem associated with this disorder. There is a lack of clear guidelines to date regarding the physiotherapy treatment of these disorders. We performed a keyword searches of Pubmed, Scopus, Sciencedirect, Cochrane and PEDro databases. In total, 555 references were retrieved, of which only 55 fulfilled the inclusion criteria. Publications were grouped by the main symptoms caused by haemophilia and the physiotherapy treatments available. The literature reviewed shows that physiotherapists have a range of therapeutic tools at their disposal for the treatment of the main musculoskeletal disorders suffered by patients with haemophilia. Physiotherapy interventions act upon inflammation and pain, as well as favouring the reabsorption of haematomas, preventing muscle fibrosis and joint ankylosis and recovering the joint range from prior to the lesions. Also, these interventions help prevent muscle atrophy and provide patients with the optimal physical conditions for facing the small and repetitive injuries that, over time, can have a detrimental effect on their quality of life.

CONCLUSION

Haemophilic patients suffer from a series of musculoskeletal disorders, which are associated with important functional disability. Physiotherapy and adapted sports are essential for decreasing disability and improving the quality of life of affected patients.

Health promotion for young patients with haemophilia

The haemophilia treatment centre of the Clinic for Children and Youth Medicine in Jena extends medical care by health-promotion measures, namely: health counselling, adjuvant exercise therapy and school sports. In addition to the regular medical checks at the treatment centre patients are examined regarding physical fitness, joint situation, quality of life in general and disease-specific manner, as well as psycho-social and nutritional behaviour. Findings and medical results of the examinations are integrated into an individual advice on therapy, school sports, and health recommendations. This aimed at strengthening health-related resources and minimizing potential injuries. First long-term evaluation shows an increase of activity behaviour and physical fitness without increasing bleeding rate and maintained joint function.

CONCLUSION

Combining functional prevention diagnostics and individual health counselling shows signs of improved patient's health knowledge, self-competence and physical fitness.

Hemophilia in Sports: A Case Report and Prophylactic Protocol

OBJECTIVE

 To describe a successful prophylactic protocol for managing an athlete with hemophilia playing at a high level of contact sports.

BACKGROUND

 Published data show that team physicians are not comfortable either treating athletes with bleeding disorders or allowing them to participate in contact sports. Much of the literature historically has recommended against allowing athletes with bleeding disorders to play sports at all and certainly against playing contact sports. Hemophilia treatment can now include prophylactic injections of recombinant factor VIII to prevent bleeding episodes. Modern treatments hold the promise of allowing athletes with hemophilia to participate in contact sports.

DIFFERENTIAL DIAGNOSIS

 Mild, moderate, or severe hemophilia; von Willebrand disease; other factor deficiencies.

TREATMENT

 A treatment protocol was developed that included prophylactic factor VIII injections on a regular basis and when the athlete was injured.

UNIQUENESS

 This is the first published case report of an athlete with known hemophilia being successfully treated and participating in National Collegiate Athletic Association collegiate basketball for 2 full seasons.

CONCLUSIONS

 Sports medicine teams can successfully manage an athlete with hemophilia playing a contact sport.

Capacity Building for Rare Bleeding Disorders in the Remote Commonwealth of the Northern Mariana Islands

The US Pacific Commonwealth of the Northern Mariana Islands is home to an underserved hemophilia population. We developed a strategy in 2014 to build sustainable island-wide medical, patient and family, and community support for this rare disease. Collaboration with regional bleeding disorder leadership galvanized a weeklong conference series. More than 200 participants attended discipline-specific seminars; pre-post test evaluations documented educational benefits. This time-concentrated island-wide education intervention promoted the rapid identification of new cases and stimulated sustainable bleeding disorder care development. The education series proved feasible, efficient, and effective in increasing knowledge and reducing patient and professional isolation, serving as a model for improving capacity for orphan diseases (those that affect fewer than 200 000 people in any particular country) in underresourced areas.

Physical activity and health outcomes in persons with haemophilia B

Regular participation in physical activity helps to prevent damage and maintain joint health in persons with haemophilia. This study describes self-reported physical activity participation among a sample of people with haemophilia B in the US and measures its association with health-related quality of life (HRQoL). Data on 135 participants aged 5-64 years were abstracted from Hemophilia Utilization Group Study Part Vb. The International Physical Activity Questionnaire assessed physical activity among participants aged 15-64 years, and the Children's Physical Activity Questionnaire abstracted from the Canadian Community Health Survey was used for participants aged 5-14 years. SF-12 was used to measure HRQoL and the EuroQol (EQ-5D-3L) was used to measure health status for participants older than 18 years of age. PedsQL was used to measure HRQoL in children aged 5-18 years. Sixty-two percent of participants in the 15-64 year-old age cohort reported a high level of physical activity, 29% reported moderate activity and 9% reported low activity. For children aged 5-14 years, 79% reported participating in physical activity for at least 4 days over a typical week. Based on the 2008 Physical Activity Guidelines for Americans, 79% of adults achieved the recommended physical activity level. Multivariable regression models indicated that adults who engaged in a high level of physical activity reported EQ-5D Visual Analogue Scale (VAS) scores that were 11.7 (P = 0.0726) points greater than those who engaged in moderate/low activity, indicating better health outcomes. Among children, no statistically significant differences in health outcomes were found between high and moderate or low activity groups.

Overweight and obesity in hemophilia: a systematic review of the literature

CONTEXT

As life expectancy in individuals with congenital hemophilia approaches that of the general population, we hypothesize that public health risks, including overweight and obesity, also follow a similar trend.

EVIDENCE ACQUISITION

A search of the literature included terms relating to overweight, sequelae of being overweight, and hemophilia. Studies were included if they reported the frequency or clinical significance of known complications of overweight and obesity, including musculoskeletal disease, aerobic capacity, cardiovascular disease, diabetes, hyperlipidemia, decreased quality of life, and change in pharmacokinetics of infused clotting factor in hemophilia. Recommendations from medical organizations were searched for preventive and management strategies applicable to this population.

EVIDENCE SYNTHESIS

Overweight and obesity are now more prevalent in the hemophilia population than previous generations, with rates similar to and, in certain subsets even higher, than that of the general population. Increased BMI leads to limitations in joint range of motion in the general population and even more so in persons with hemophilia.

CONCLUSIONS

Overweight and obesity in hemophilia are an increasing problem. Simple steps can be taken to encourage patients to decrease caloric intake and increase physical activity. Prevention and management of overweight, obesity, and their sequelae must be addressed in clinical practice in order to maximize the overall health of the hemophilia population.

Psychosocial aspects of haemophilia: a systematic review of methodologies and findings

Psychosocial factors have a significant impact on quality of life for patients with chronic diseases such as haemophilia. Interventions to support the psychosocial needs of patients and their families, such as offering information and assistance, clarifying doubts, and teaching coping strategies to minimize the impact of disabilities, may help to maximize patient outcomes and improve quality of life for their families. The aim of this study was to evaluate the current literature on psychosocial aspects of haemophilia. Literature searches were performed using the PubMed database to identify studies evaluating psychosocial stressors in persons with haemophilia. Articles pertaining to the HIV epidemic were excluded from the analysis, as were those published before 1997. The literature reviews identified 24 studies, covering a range of different populations, generally with small cohorts (n < 100). Most studies were questionnaire based, with almost no overlap in terms of the instruments used. Only one study combined questionnaire techniques with qualitative methods. Except for two European studies, all publications reported data from a single country. Overall, studies tended to show that quality of life is reduced in persons with haemophilia, with a potential impact on education and employment, particularly when prophylactic treatment is not available. Carrier status in women may have a psychosocial impact and affect reproductive choices. Data on psychosocial aspects of the haemophilia life cycle are lacking in the published literature, along with data from developing countries. There is a need for more international, multifaceted research to explore and quantify the social and psychological aspects of life with haemophilia.

Effects of a 6-week, individualized, supervised exercise program for people with bleeding disorders and hemophilic arthritis

BACKGROUND

People with bleeding disorders may develop severe arthritis due to joint hemorrhages. Exercise is recommended for people with bleeding disorders, but guidelines are vague and few studies document efficacy. In this study, 65% of people with bleeding disorders surveyed reported participating in minimal exercise, and 50% indicated a fear of exercise-induced bleeding, pain, or physical impairment.

OBJECTIVE

The purpose of this study was to examine the feasibility, safety, and efficacy of a professionally designed, individualized, supervised exercise program for people with bleeding disorders.

DESIGN

A single-group, pretest-posttest clinical design was used.

METHODS

Thirty-three patients (3 female, 30 male; 7-57 years of age) with mild to severe bleeding disorders were enrolled in the study. Twelve patients had co-existing illnesses, including HIV/AIDS, hepatitis, diabetes, fibromyalgia, neurofibromatosis, osteopenia, osteogenesis imperfecta, or cancer. Pre- and post-program measures included upper- and lower-extremity strength (force-generating capacity), joint range of motion, joint and extremity circumference, and distance walked in 6 minutes. Each patient was prescribed a 6-week, twice-weekly, individualized, supervised exercise program. Twenty participants (61%) completed the program.

RESULTS

Pre- and post-program data were analyzed by paired t tests for all participants who completed the program. No exercise-induced injuries, pain, edema, or bleeding episodes were reported. Significant improvements occurred in joint motion, strength, and distance walked in 6 minutes, with no change in joint circumference. The greatest gains were among the individuals with the most severe joint damage and coexisting illness.

LIMITATIONS

Limitations included a small sample size with concomitant disease, which is common to the population, and a nonblinded examiner.

CONCLUSIONS

A professionally designed and supervised, individualized exercise program is feasible, safe, and beneficial for people with bleeding disorders, even in the presence of concomitant disease. A longitudinal study with a larger sample size, a blinded examiner, and a control group is needed to confirm the results.

Psychosocial correlates of physical activity in adolescents with haemophilia

Boys with haemophilia are now encouraged to exercise and take part in physical activities, but actual measures of time spent in active participation is lacking. The aim of this study was to obtain an objective measure of daily physical activity in boys with haemophilia as compared with healthy controls. The study also aimed to ascertain the social and cognitive factors associated with exercise in this population. Seventeen patients (aged 11-18 years) with haemophilia were studied and compared with 44 healthy controls (aged 10-16.5 years). Physical activity was measured by accelerometry. Psychosocial correlates were assessed using validated questionnaires. Measured physical activity levels in subjects with haemophilia were slightly higher than for the control group. Both groups spent 70% of the day inactive, with similar proportions of time in moderate and vigorous activity. Subjects with haemophilia had a favourable self-image and similar levels of anxiety as peers without a bleeding disorder. Self-efficacy scores were lower than for controls suggesting increased sensitivity to barriers and lack of acceptance of alternatives. Health beliefs did not influence physical activity, but a negative correlation of time spent in high or vigorous activity with scores for support-seeking was observed. The data demonstrate that in the appropriate social environment and with medical support, patients with haemophilia may be as physically active as their peers without a bleeding disorder. Further investigation into the psychosocial barriers of physical activity in patients with haemophilia is needed to more effectively encourage healthy behaviours.

Athletic participation in severe hemophilia: bleeding and joint outcomes in children on prophylaxis

OBJECTIVES

We sought to determine joint outcomes relative to impact level of athletic participation among school-aged children who had hemophilia and were taking prophylactic factor replacement, as well as to investigate prognostic factors for joint outcomes.

METHODS

School-aged boys with severe hemophilia A or B at a single center were included in the study. Clinical data on baseline joint status, BMI, hemophilia treatment, bleeding episodes, joint assessments, athletic participation, and injuries were retrospectively reviewed. Data on athletic participation were supplemented, when incomplete in the medical record, via structured telephone interview.

RESULTS

Among 37 children with severe hemophilia A or B receiving factor prophylaxis, 73% participated in high-impact activities, whereas 27% participated in exclusively low-impact activities. The frequency of joint hemorrhages and new injuries did not appreciably differ between high- and low-impact athletics. In most instances, children developed <1 bleed or injury per season. A new target joint developed in 1 (3%) child. Sixteen percent of children met established BMI criteria for overweight, and 3% were obese. In logistic regression analyses with adjustment for prophylaxis frequency, level of athletic participation was not a significant prognostic factor for joint hemorrhage.

CONCLUSIONS

In the setting of regular prophylaxis and adult coaching and supervision, significant bleeding complications were uncommon and level of impact of athletic participation was not a prognostic factor for joint outcomes. Athletic participation with appropriate supervision and precautions should be encouraged in children with hemophilia receiving prophylaxis, given potential health benefits in an increasingly overweight pediatric population.