Health-related quality of life and psychological well-being in elderly patients with haemophilia

Laying the foundations for gene therapy in Italy for patients with haemophilia A: A Delphi consensus study

INTRODUCTION

Current treatment for haemophilia A involves factor VIII replacement or non-replacement (emicizumab) therapies, neither of which permanently normalise factor VIII levels. Gene therapy using adeno-associated viral (AAV) vectors is an emerging long-term treatment strategy for people with severe haemophilia A (PwSHA) that is likely to be available for clinical use in the near future.

AIM

This article proposes practical guidelines for the assessment, treatment, and follow-up of potential PwSHA candidates for AAV-based gene therapy.

METHOD

Using the Delphi method, a working group of Italian stakeholders with expertise in and knowledge of the care of adults with haemophilia A analysed literature for AAV-based gene therapy and drafted a list of statements that were circulated to a panel of Italian peers. During two rounds of voting, panel members voted on their agreement with each statement to reach a consensus.

RESULTS

The Delphi process yielded 40 statements regarding haemophilia A gene therapy, across five topics: (1) organisational model; (2) multidisciplinary team; (3) patient engagement; (4) laboratory surveillance; and (5) patient follow-up and gene therapy outcomes. The consensus was reached for all 40 statements, with the second round of voting needed for five statements.

CONCLUSION

Use of the hub-and-spoke organisational model and multidisciplinary teams are expected to optimise patient selection for gene therapy, as well as the management of dosing and patient follow-up, patient engagement, laboratory surveillance, and patient expectations regarding outcomes. This approach should allow the benefits of AAV-based gene therapy for haemophilia A to be maximised.

Cardiovascular Risk Factors in Patients with Congenital Hemophilia: A Focus on Hypertension

Aging hemophiliacs face cardiovascular disease. Lots of evidence has been gathered that hemophiliacs have a more unfavorable cardiovascular profile than the general population does, especially due to the increased prevalence of hypertension (HTN). Among the existing scattered evidence, our study provides the most comprehensive and systematized analysis of the determinants of HTN in hemophiliacs. We discussed the contribution to the HTN substrate of hemophilia-specific factors, such as type, severity and the presence of inhibitors. The complex mechanism of kidney dysfunction in relation to hematuria and viral infections was meticulously addressed. Furthermore, we highlighted the new pathogenic concepts of endothelial dysfunction and the association between HTN and hemophilic arthropathy. The clustering of cardiovascular risk factors is common in hemophiliacs, and it enhances the negative vascular effect of HTN and aggravates HTN. It usually leads to an increased risk for coronary and cerebrovascular events. Our work provides reliable evidence to guide and improve the management of HTN in hemophiliacs.

The Limitations and Unmet Needs of the Five Cornerstones to Guarantee Lifelong Optimization of Prophylaxis in Hemophilia Patients

Prophylaxis to prevent bleeding is highly recommended for hemophilia patients. The development of new drugs and tools for modeling personalized prophylaxis provides the means for people with hemophilia to lead active lives with a quality of life comparable to that of nonhemophilic individuals. The choice of regimens must be made on a highly individual basis. Unfortunately, reference guides neither always concur in their recommendations nor provide directions to cover all possible scenarios. In this review, a group of experts identify the significant limitations and unmet needs of prophylaxis, taking advantage of their clinical experience in the disease, and supported by a rigorous literature update. To perform a more systematic and comprehensive search for gaps, the main cornerstones that influence decisions regarding prophylactic patterns were first identified.

Bleeding phenotype, joint status, physical activity, pharmacokinetics/medication properties, and adherence to treatment were considered as the primary mainstays that should allow physicians guiding prophylaxis to secure the best outcomes. Several challenges identified within each of these topics require urgent attention and agreement. The scores to assess severity of bleeding are not reliable, and lead to no consensus definition of severe bleeding phenotype. The joint status is to be redefined in light of new, more efficient treatments with an agreement to establish one scale as the unique reference for joint health. Further discussion is needed to establish the appropriateness of high-intensity physical activities according to patient profiles, especially because sustaining trough factor levels within the safe range is not always warranted for long periods. Importantly, many physicians do not benefit from the advantages provided by the programs based on population pharmacokinetic models to guide individualized prophylaxis through more efficient and cost-saving strategies. Finally, ensuring correct adherence to long-term treatments may be time-consuming for practitioners, who often have to encourage patients and review complex questionnaires.

In summary, we identify five cornerstones that influence prophylaxis and discuss the main conflicting concerns that challenge the proper long-term management of hemophilia. A consensus exercise is warranted to provide reliable guidelines and maximize benefit from recently developed tools that should notably improve patients' quality of life.

Quality of life and clinical assessment of joint health in children with hemophilic arthropathy

Background

Hemophilic arthropathy results in pain, deformity, and disability with severe impairments, activity limitation, and thus productivity loss. Also patterns of treatment interfere with patients’ life, so the quality of life should be assessed when evaluating treatment. The aim of this work was to assess the quality of life of children with hemophilic arthropathy and its relation to clinical joint health.

Results

The study was carried out on fifty boys with hemophilic arthropathy. All patients were subjected to thorough local clinical assessment of the most affected and/or target joint using Hemophilia Joint Health Score (HJHS 2.1) and assessment of quality of life using Haemo quality of life (Haemo-Qol) questionnaire children and parent versions. Among the fifty hemophilic patients, 36 (72%) patients were hemophilia A and 14 (28 %) patients were hemophilia B. The age at first hemarthrosis ranged from 1 to 8 years with a mean of 2.40±1.78. While the number of joints affected in the studied patients ranged from 2 to 13 joints with a mean of 7±3.25. As regards the severity, 23 patients (46%) had severe, and 27 (54%) had moderate hemophilia. Forty four (88%) patients had different degrees of anemia. There was significant correlation between child Haemo-QoL with degree of anemia (r = 0.291, P = 0.040), mainly with view and school dimensions. There were significant correlations between child and parent Haemo-QoL and HJHS with each of the following: factor activity level, duration of the disease, duration of joint disease, number of bleeding attacks last year, and number of joints affected. Synovectomy was done for 5 (10%) patients. The total child Haemo-QoL score was statistically significantly lower after the intervention (P=0.043), with a significant improvement in physical health, feeling, view, family, school and sports, treatment, and dealing dimensions. In the current study, there were significant positive correlations between child and parent Haemo-QoL and HJHS scores.

Conclusions

The quality of life in patients with hemophilic arthropathy was influenced by the joint health, factor activity level, disease duration, number of bleeding attacks, number of joints affected (during life), duration of joint disease, and presence of hepatitis C virus.

Health-related quality of life of patients with haemophilia: a cross-sectional survey in the Northeast of China

INTRODUCTION

Haemophilia is a hereditary, chronic and haemorrhagic disorder caused by a deficiency in coagulation factors. Long-term spontaneous bleeding of joints and soft tissues can seriously affect the quality of life of patients.

OBJECTIVE

The study aimed to assess the health-related quality of life (HRQoL) of patients with haemophilia and associated factors.

METHODS

A snowball sampling strategy was adopted to select study participants. Eligible participants were those who were 18 years or older and had mild, moderate or severe haemophilia. They were asked to self-complete a questionnaire, collecting data regarding their sociodemographic characteristics, target joint status and HRQoL measured by the EQ-5D-5L(a tool developed by the European quality of life (EuroQol) Group).

RESULTS

The respondents reported a mean EQ-5D_utility(country-specific valuesets for the EQ-5D-5L) score of 0.51 (SD=0.34). Those with severe haemophilia had a lower utility score than those with mild/moderate haemophilia (0.46±0.37 vs 0.56±0.30, p=0.737). The linear regression analyses showed that older age (>25 years), two or more target joints, not working, low levels of knowledge of the disease and borrowing money to pay for medical treatments were associated with lower EQ-5D_utility scores.

CONCLUSION

Low HRQoL of patients with haemophilia is evident in China. Social support needs to be strengthened to address this issue.

Bioengineering hemophilia A-specific microvascular grafts for delivery of full-length factor VIII into the bloodstream

Hemophilia A (HA) is a bleeding disorder caused by mutations in the F8 gene encoding coagulation factor VIII (FVIII). Current treatments are based on regular infusions of FVIII concentrates throughout a patient's life. Alternatively, viral gene therapies that directly deliver F8 in vivo have shown preliminary successes. However, hurdles remain, including lack of infection specificity and the inability to deliver the full-length version of F8 due to restricted viral cargo sizes. Here, we developed an alternative nonviral ex vivo gene-therapy approach that enables the overexpression of full-length F8 in patients' endothelial cells (ECs). We first generated HA patient-specific induced pluripotent stem cells (HA-iPSCs) from urine epithelial cells and genetically modified them using a piggyBac DNA transposon system to insert multiple copies of full-length F8. We subsequently differentiated the modified HA-iPSCs into competent ECs with high efficiency, and demonstrated that the cells (termed HA-FLF8-iECs) were capable of producing high levels of FVIII. Importantly, following subcutaneous implantation into immunodeficient hemophilic (SCID-f8ko) mice, we demonstrated that HA-FLF8-iECs were able to self-assemble into vascular networks, and that the newly formed microvessels had the capacity to deliver functional FVIII directly into the bloodstream of the mice, effectively correcting the clotting deficiency. Moreover, our implant maintains cellular confinement, which reduces potential safety concerns and allows effective monitoring and reversibility. We envision that this proof-of-concept study could become the basis for a novel autologous ex vivo gene-therapy approach to treat HA.

Effectiveness of hypnosis for pain management and promotion of health-related quality-of-life among people with haemophilia: a randomised controlled pilot trial

Joint deterioration and associated chronic pain are common among people with haemophilia (PWH), having an impact on quality-of-life. Though non-pharmacological strategies are recommended, psychological interventions to promote pain control and quality-of-life have scarcely been tested in haemophilia. This randomised controlled pilot trial aimed to assess feasibility, acceptability and effectiveness of hypnosis for pain management and promotion of health-related quality-of-life (HRQoL) among PWH. Twenty adults were randomised either to four weekly hypnosis sessions plus treatment-as-usual (experimental group; EG) or treatment-as-usual only (control group; CG). Participants completed sociodemographic and clinical assessment, measures of pain, HRQoL and emotional distress before (T1) and after (T2) intervention. Changes were analysed by calculating the differences between T1 and T2, and the groups were compared through independent-sample t tests (or chi-squared). Retention rates (90%) and analysis of patient satisfaction showed good acceptability and feasibility of the intervention. The EG (n = 8) had a higher reduction on pain interference than the CG (n = 10) (d = −0.267). A higher improvement on HRQoL (EQ-5D index: d = 0.334; EQ-5D VAS: d = 1.437) and a tendency towards better haemophilia-related quality-of-life (A36-Hemofilia QoL) were also evident in the EG. This is the first study showing the effectiveness of hypnosis to reduce pain interference and promote HRQoL among PWH.

Coping strategies in young and adult haemophilia patients: A tool for the adaptation to the disease

INTRODUCTION

Chronic diseases, after diagnosis, involve changes that have to favour coping with the new situation. The resources used will help control, manage and adapt to the disease. The psychological aspects may be influencing how the individual faces the situation.

AIM

To assess whether perceptions or beliefs and illness behaviour influence the choice of coping strategies for young and adult patients with haemophilia.

METHODS

Multicenter cross-sectional descriptive study. We recruited 63 patients with haemophilia A and B, adolescents, young and adults, and both types of treatment. A clinical and sociodemographic data sheet, the Coping Strategies Inventory (CSI), the Illness Perception Questionnaire-revised (IPQ-R) and the Illness Behaviour Questionnaire (IBQ) were used.

RESULTS

Patients with haemophilia use appropriate coping strategies, both cognitive and behavioural. Most of them are on-demand treatment, and despite arthropathy, they perceive good control of haemophilia. However, patients in prophylactic treatment are those employed more maladaptive coping strategies, less perception of control and hypochondriacal behaviour to the disease. The age variable may be relevant but we did not find significant differences.

CONCLUSIONS

Coping strategies used by patients with haemophilia are adequate. Although it is noted that the perception of the disease, its controllability or not, affects illness behaviour and consequently how coping with haemophilia. These are based on personal characteristics, cognitive and attitudinal dispositions that the individual consciously use to solve or face adverse situations. The analysis of coping styles of patients could be a tool for professionals to manage properly the disease.

Feasibility and Results of a Mobile Haemophilia Outpatient Care Pilot Project

Introduction Regular visits at haemophilia treatment centres (HTCs) in rural regions are often dependent on the access to a private car due to lack of or limited availability of public means. Therefore, a mobile haemophilia outpatient care (MHOC) concept providing home visits to haemophilia patients has been developed by the Saarland HTC, which is located in a rural German region.

Methods Haemophilia patients and their parents were home visited at least twice (baseline, follow-up) by trained medical staff. Socio-demographic and clinical data were collected and interviews were performed asking the patients and parents about their needs and expectations towards such a MHOC.

Results Seventy-nine patients were enrolled (56 adults, 23 children), 62.0% severely affected, 48.1% on prophylaxis, with a mean age of 37.4 ± 16.4 years (17–78) and 9.8 ± 4.2 years (3–16), respectively. Median travel distance to the HTC was 43.5 km (3–200). Note that 92.4% considered an intense binding to the HTC and a MHOC concept as ‘rather/very important’ (88.6%). They expected from a MHOC to provide consulting and educating activities, support in elderhood issues and treatment. For 35.4%, a MHOC could currently provide additional support, mainly due to patient's immobility and need of consultancy. They mainly used services in terms of consultancy in social–legal affairs and support in contacting authorities.

Conclusion The results of this study support the hypothesis that a MHOC concept is a needful supplement in haemophilia comprehensive care and will improve the challenging haemophilia treatment, especially for those with limited access to HTCs or with disabilities.

Health-Related Quality of Life and Psychological Aspects of Adults With Hemophilia in Iran

Hemophilia causes bleeding that may affect patients’ psychological aspects and quality of life. This study aims to evaluate the impact of psychological aspects and pain on health-related quality of life (HRQoL) in adult patients with hemophilia. This cross-sectional study was conducted on 103 patients with hemophilia. Data were collected using hemophilia-specific quality of life, Depression Anxiety Stress Scales, and pain visual analogue scales. Data were analyzed using correlation coefficients, analysis of covariance, and regression analysis. The results showed that 71.7% of patients with hemophilia experienced pain on the study day. The mean score of HRQoL of patients with hemophilia was 51.09 (standard deviation = 19.37). Moreover, 57.4%, 64.6%, and 44.6% of the patients had mild to severe depression, anxiety, and stress, respectively. In addition, a significant association was observed between HRQoL and depression, anxiety, and severity of pain. In the regression model, 48% of changes in HRQOL were explained by the study variables, with the severity of pain and depression being significant predictors. Therefore, attention should be paid to these aspects to improve patients’ quality of life and psychosocial health.

Health-Related Quality of Life and Association With Arthropathy in Greek Patients with Hemophilia

Health-related quality of life (HRQoL) is increasingly implicated in contemporary hemophilia management. This study focuses on the assessment of HRQoL in Greek patients with hemophilia and the comparison with normative data from the general population, as well as on the extent arthropathy may affect the patients’ HRQoL. One hundred and nine adult patients completed the Greek social functioning (SF-36) and Haem-A-QoL questionnaires. Arthropathy was assessed by both the World Federation of Hemophilia clinical score and Pettersson radiological score. The most impaired domains of Haem-A-QoL were sports/leisure (SL) and physical health (PH; mean scores 61.2 and 42.2, respectively). The patients experienced statistically significant lower mean scores in all SF-36 domains than the normative sample, especially in role physical (RPH), bodily pain (BP), and general health (GH) subscales. Among Haem-A-QoL subscales, SL and PH were found strongly associated with severity of arthropathy using both orthopedic scores (P < .001), and maintained the statistical significance after adjustment for age (P < .05). A poor orthopedic status was also negatively associated with certain SF-36 subscales. However, none of these correlations remained after adjustment with age. Compared to normative data from Greece, patients with hemophilia showed deterioration in all HRQoL subscales, with a more pronounced effect in RPH, BP, and GH subscales. Health-related quality of life was strongly influenced by arthropathy, mainly in the physical aspects of HRQoL. The use of the disease-specific Haem-A-QoL tool can capture additional associations between HRQoL and hemophilic arthropathy.

Social/economic costs and quality of life in patients with haemophilia in Europe

OBJECTIVE

The aim of this study was to determine the economic burden from a societal perspective and the health-related quality of life (HRQOL) of patients with haemophilia in Europe.

METHODS

We conducted a cross-sectional study of patients with haemophilia from Bulgaria, France, Germany, Hungary, Italy, Spain Sweden and the UK. Data on demographic characteristics, health resource utilisation, informal care, loss of labour productivity and HRQOL were collected from the questionnaires completed by patients or their caregivers. HRQOL was measured with the EuroQol 5-domain (EQ-5D) questionnaire. The costs have been estimated from a societal perspective adopting a bottom-up approach.

RESULTS

A total of 401 questionnaires were included in the study, of which 339 were collected from patients with haemophilia and 62 from caregivers. The lowest average annual cost per person was reported in Bulgaria (€6,660) and the highest in Germany (€194,490). Our results demonstrate both a large difference from country to country in the average annual cost per patient in 2012 and the driving role of drugs in costs. Drugs represent nearly 90 % of direct healthcare costs in a majority of the countries analysed (Hungary, Italy, Spain and Germany). In Bulgaria, France and Sweden, however, healthcare services (visits, tests and hospitalisations) prevail. Costs are also shown to differ between children and adults. The mean EQ-5D index score for adult patients was 0.69 and mean EQ-5D VAS was 66.6. The mean EQ-5D index score for carers was 0.87 and mean EQ-5D VAS was 75.5. In the disability score, 60 % showed no disability and measuring caregiver burden with the Zarit Index produced an overall mean score of 25.3.

CONCLUSION

We have shown that haemophilia is associated with a substantial economic burden and impaired HRQOL. Studies on cost of illness and HRQOL are important for haemophilia as the future of this disease is likely to change with the development of new innovative treatments. The introduction of these treatments will most likely impact future costs related to haemophilia.

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.

Persons with Haemophilia in Sweden- Experiences and Strategies in Everyday Life. A Single Centre Study

Introduction/Aim

Haemophilia is caused by deficiency in coagulation factor VIII or IX. Treatment with the missing coagulation factors has been available in most developed countries for several decades. The aim was to explore the experiences of adults living with severe or moderate haemophilia and their coping strategies at a single centre in Sweden.

Method

The interview study had a qualitative empirical approach and was analyzed on the basis of the method empirical phenomenological psychology. The sample included 14 participants, mean age 42 (19–80 y), who met the inclusion criteria and to saturation of information. Results: General characteristics were; All were satisfied with and grateful for access to medication. An acceptance of the disorder and willingness to live a normal life was identified among all participants. They were all content with the care provided by Haemophilia Treatment Centre (HTC) and felt supported by its multidisciplinary team. Four typologies were identified; Protective adults and assertive children during up-bringing, finding a role in social context, symptoms and treatments, fear of limited resources in the future. Task-, emotional- and avoidance coping strategies were seen in the interviews. The most prominent coping strategy was task oriented.

Conclusion

This interview study with Swedish PWH shows that they strive for normality and adaptation in social activities throughout life finding their own niche. The PWH expressed the importance of knowledge and support from the comprehensive medical team at HTC and therefore it seems important to continue comprehensive medical care at HTC in order to follow-up the haemophilia persons regularly.

The social burden and quality of life of patients with haemophilia in Italy

BACKGROUND

In Italy, the project on the social burden and quality of life (QoL) of patients with haemophilia investigates costs from a society perspective and provides an overview of their quality of life. Moreover, as life expectancy increased in recent years along with new treatment strategies implemented in the last decades, it analyses trends of costs other than drugs simulating impacts during patient whole life.

MATERIAL AND METHODS

We ran a web-based cross-sectional survey supported by the Italian Federation of Haemophilia Societies in recruiting patients with haemophilia and their caregivers. We developed a questionnaire to collect information on demographic characteristics, healthcare and social services consumption, formal and informal care utilisation, productivity loss and quality of life. In particular, quality of life was assessed through the EuroQoL tool. Last, we applied the illness cost method from a society perspective.

RESULTS

On average, quality of life is worse in adult patients compared to child and caregivers: more than 75% of adult patients declare physical problems, 43% of adult patients and 54% of their parents have anxiety problems. Assuming a society perspective, the estimated mean annual total cost per patient in 2012 is 117,732 €. Drugs represent 92% of total costs. Focusing on costs other than drugs, each additional point of EuroQoL tool implies a costs' reduction of 279 €. The impact of age varies across age groups: each added year implies a total decrease of costs up to 46.6 years old. Afterwards, every additional year increases costs.

DISCUSSION

Quality of life of patients with haemophilia and their caregivers improved and it influences positively on consumed resources and on their contribution to the social-economic system. Costs other than drugs for patients with haemophilia follow the same trends of general population.

Quality of life and functional capacity of elderly women with knee osteoarthritis

OBJECTIVE

To correlate functional ability and quality of life of elderly women with knee osteoarthritis.

METHODS

Cross-sectional study composed of 40 elderly women with knee osteoarthritis. We used the following instruments: identification questionnaire, Western Ontario and McMaster Universities Arthritis Index (WOMAC), and World Health Organization Quality of Life Questionnaire-OLD (WHOQOL-OLD). The significance level was 0.05 (5%), and confidence intervals were 95%. For statistical analysis we used parametric statistical tests, descriptive analysis, test for equality of two proportions, Pearson's correlation, correlation test, and analysis of variance.

RESULTS

The mean age (± standard deviation) was 74.1 (± 6.7) years, and 47.5% of patients had osteoarthritis in both knees. Moderate pain was reported by 45% of patients when they walked on a flat plane and 40% when they were seated or lying down; 55% had severe or very severe pain when climbing or descending stairs; 50% reported moderate joint stiffness after sitting, lying, or resting; and 65% reported moderate or little stiffness after waking. In physical function, 60% of patients had moderate or severe difficulty in descending stairs and 67.5%, when climbing stairs; 60% reported severe or very severe difficulty in getting in and out of the car, and 70%, when performing strenuous housework. The correlation with WHOQOL-OLD and WOMAC was negative and not significant except for autonomy, which was significant. Sedentary and elderly women who used walking aid devices had worse WOMAC functional capacity, but this finding was not statistically significant. In WHOQOL-OLD, volunteers scored higher on social participation and engagement in physical activity on autonomy, which was statistically significant compared with the nonvoluntary and sedentary domains, respectively.

CONCLUSION

It is possible to have a good quality of life even with functional impairment from knee osteoarthritis.

The effects of repetitive haemarthrosis on postural balance in children with haemophilia

Sensory information from visual, vestibular and proprioceptive systems is necessary to control posture and balance. Impairment in proprioception due to repetitive joints bleeding may lead to a deficit in postural balance which, in turn, leads to high joint stress and risk of bleeding recurrence. Despite the increase in attention in this field during the past few years, the data concerning to how bleeds can affect postural control in children with haemophilia (CWH) remain scarce. This study aimed to evaluate the postural balance in CWH. Twenty CWH Haemophilia Group (HG) and 20 age-matched children Control Group (CG) were recruited to this study. A force plate was used to record centre of pressure (COP) displacement under four different postural conditions during quiet standing: eyes open on firm surface, eyes open on foam surface, eyes closed on firm surface and eyes closed on a foam surface. Variables of COP as sway area and mean velocity and in anterior-posterior (y) medio-lateral (x) direction were processed and for each variable sensory, quotients were calculated and compared between groups. No differences were found in visual and vestibular quotients variables between groups. A higher value was found in sway area variable on proprioception quotient in the HG when compared with CG (P = 0.042). CWH with repetitive joint bleed on lower limbs showed differences in postural balance when compared with non-haemophiliac children. The identification of early balance impairments in CWH can help us understand better the effects of bleeds inside joints on postural control and plan a more effective preventive and rehabilitative treatment.