Hemophilic Arthropathy: Barriers to Early Diagnosis and Management

Radiographs in Pediatric Rheumatology: Where Do We Stand?

Rheumatic disorders in children include inflammatory arthritis, inflammatory bone disorders such as chronic nonbacterial osteomyelitis (CNO), connective tissue disorders, and vasculitides (juvenile dermatomyositis, scleroderma). The diagnosis in these children is based on a combination of history, clinical examination, and laboratory investigations. Radiographs play an important role in children with arthritis, who have atypical presentation or for assessment of disease-related damage and differentiation from mimics. Further, radiographs also have an ancillary role in the assessment of musculoskeletal disorders such as dermatomyositis and hemophilia. This review seeks to present a detailed analysis of the specific indications and advantages of radiographs in the situations. Further, a structured reporting format for assessment of radiographs in pediatric rheumatic disorders has also been presented for the reader's reference.

Performance of instrumental activities of daily living in patients with haemophilic arthropathy. A cross-sectional cohort study

BACKGROUND

The development of haemophilic arthropathy causes joint damage that leads to functional impairment that limits the performance of activities in patients with haemophilia. The aim was to identify the best predictive model for performing instrumental activities of daily living in adult patients with haemophilia arthropathy.

METHODS

Cross-sectional cohort study. 102 patients were recruited. The dependent variable was the performance of instrumental activities of daily living (Lawton and Brody scale). The dependence on the performance of activities of daily living was the dependent endpoint (Barthel scale). The secondary variables were joint damage (Hemophilia Joint Health Score), pain intensity, and clinical, anthropometric, and sociodemographic variables.

RESULTS

The degree of dependence, joint damage, pain intensity, and marital status (Cp = 5.60) were the variables that best explain the variability in the performance of instrumental activities of daily living (R2 adj = 0.51). Loss of predictive capacity is acceptable with good mean internal (R2 mean = 0.40) and external (R2-r2 = 0.09) validation. According to the predictive pattern obtained, patients with haemophilia, who were married, without joint pain or damage, and independent in their day-to-day lives, had a score of 7.91 points (95% CI: 7.42; 8.39) in the performance of instrumental activities of daily living.

CONCLUSIONS

The predictive model for the functional capacity of instrumental activities of daily living in haemophilia patients encompasses factors such as level of autonomy, joint impairment, pain severity, and marital status. Notably, despite the presence of joint damage, individuals with haemophilia exhibit a significant level of independence in carrying out both basic daily tasks and instrumental activities of daily living.

INTERNATIONAL REGISTRATION NUMBER

Id NCT04715100.

Immersive VR movement visualization in patients with hemophilic knee arthropathy: randomized, multicenter, single-blind clinical trial

PURPOSE

To evaluate the efficacy of an immersive movement visualization intervention in patients with hemophilia and hemophilic knee arthropathy.

MATERIALS AND METHODS

Randomized, single-blind clinical study. Twenty-eight patients with hemophilia were recruited. Patients were randomized to an experimental group (four weeks of immersive movement visualization) and a control group (no intervention). The intensity of pain, pressure pain threshold in the knee, tibialis anterior muscle, lower back level, conditioned pain modulation, range of knee motion, and lower limb functionality were evaluated.

RESULTS

There were statistically significant differences in the intergroup effect on knee pain intensity (F = 23.71; p < 0.001) and lower limb functionality (F = 7.11; p = 0.003). 42.86% of the patients in the experimental group exhibited changes greater than the minimum detectable change (MDC) in functionality. 39.29% of the patients subject to the intervention experienced changes greater than the MDC in the knee pressure pain threshold.

CONCLUSIONS

Immersive motion visualization can improve the intensity of joint pain and functionality in patients with hemophilic knee arthropathy. Functionality, pressure pain threshold, and pain intensity improved in those patients who conducted immersive movement visualization.Implications for rehabilitationImmersive visualization of movement significantly improves intensity of joint pain, functionality, pressure pain threshold, joint health, and conditioned pain modulation in patients with hemophilic knee arthropathy.The fact that it is a therapy without potential aversive stimuli makes it a possible access pathway for patients with high levels of kinesiophobia and/or catastrophism.This low-cost, home-based technology allows its use in patients far from hemophilia reference centers or with difficult access to physiotherapy treatments.The immersive visualization of movement influences the democratization of treatment, in accordance with the WHO's Sustainable Development Goal 3 (health and well-being for all).

Outcome measures in hemophilia: current and future perspectives

INTRODUCTION

Hemophilia can detrimentally affect patients' quality of life and likelihood of survival. In the evolving landscape of therapies, the therapeutic gain of each treatment must be understood to accurately position it in the therapeutic armamentarium. Accordingly, appropriate outcomes must be measured with appropriate tools.

AREAS COVERED

Our narrative review (PubMed search for 'hemophilia AND outcome' until June 2023), provides a compendium of outcome measures used in hemophilia clinical research. To define each outcome measure's relative value and applicability, several characteristics are critically discussed.

EXPERT OPINION

Bleeding assessment, first annual/annualized bleeding rate, remains central in evaluating the efficacy and safety of hemophilia treatments. As modern therapies improve clinical outcomes toward zero bleeding events, this endpoint may become less sensitive to detect differences between therapeutic approaches. Technological advancements necessitate the adaptation of outcome measures to address infrequent bleeding events, age-related comorbidities, and laboratory parameters with limited comparability after different treatments. Considerable effort has been dedicated to the development of tools that comprehensively assess coagulation, such as thrombin generation assays. Patient-reported outcome measures are gaining importance although limited by their subjectivity. A definitive set of research outcome measures remains elusive. Outcomes may need to be tailored to different therapeutic interventions.

Inflammatory diseases causing joint and bone destruction: rheumatoid arthritis and hemophilic arthropathy

Various diseases and conditions cause joint disorders. Osteoarthritis (OA) is characterized by the degeneration of articular cartilage, synovitis, and anabolic changes in surrounding bone tissues. In contrast, rheumatoid arthritis (RA) and hemophilic arthropathy (HA) display marked destruction of bone tissues caused by synovitis. RA is a representative autoimmune disease. The primary tissue of RA pathogenesis is the synovial membrane and involves various immune cells that produce catabolic cytokines and enzymes. Hemophilia is a genetic disorder caused by a deficiency in blood clotting factors. Recurrent intra-articular bleeding leads to chronic synovitis through excessive iron deposition and results in the destruction of affected joints. Although the triggers for these two joint diseases are completely different, many cytokines and enzymes are common in the pathogenesis of both RA and HA. This review focuses on the similarities between joint and bone destruction in RA and HA. The insights may be useful in developing better treatments for hemophilia patients with arthropathy and osteoporosis by leveraging advanced therapeutics for RA.

Chain-mediating effects of kinesiophobia and self-efficacy on pain catastrophizing and physical activity in haemophilia patients

BACKGROUND

There is a lack of research on the relationship between pain catastrophizing, kinesiophobia, and physical activity (PA) in people with haemophilia (PWH), and the underlying mechanisms connecting these variables remain unclear.

AIM

The study's aim was to clarify the roles of kinesiophobia and self-efficacy in the relationship between pain catastrophizing and PA in PWH.

METHODS

This cross-sectional study included adult PWH at the Haemophilia Centre of a Tertiary hospital in Beijing, China. The following questionnaires were used to collect data: the general information, the International Physical Activity Short Questionnaire, the Pain Catastrophizing Scale, the Tampa Scale of Kinesiophobia Scale, and the Exercise Self-Efficacy Scale.

RESULTS

The study included a total of 187 PWH, including 154 having haemophilia A and 33 having haemophilia B. The median interquartile range of PA was 594 (198, 1554) MET-min/wk. There were significant differences in PA of patients based on age stage, treatment modality, highest pain score within the last seven days, and presence of haemophilic arthropathy (p < .05). It was showed that pain catastrophizing could directly predict PA (p < .001), accounting for 38.13% of the total effect. Pain catastrophizing also had indirect effects on PA through the mediating factors of kinesiophobia or self-efficacy, and through the chain-mediating effect of kinesiophobia and self-efficacy, accounting for 38.40%, 17.07%, and 6.40%, respectively.

CONCLUSION

The study discovered that PWH have limited PA due to pain catastrophizing. This not only directly affects their activity but also indirectly influences it through kinesiophobia and self-efficacy.

Haemophilic arthropathy: Diagnosis, management, and aging patient considerations

Gene therapy and universal use of safer, more effective, and personalised prophylactic regimens (factor, and nonfactor) are expected to prevent joint bleeding and promote joint health in persons with haemophilia (PwH). Growing evidence suggests that subclinical bleeding, with active and inactive synovial proliferation, continues and haemophilic arthropathy remains a major morbidity in PwH despite early institution of joint prophylaxis. Joint health assessment is evolving with physical examination scores complementing imaging scores. Point-of-care ultrasound is emerging as a safe, cost-effective, and readily available tool for acute determination of musculoskeletal abnormalities, serial evaluation of joints for sonographic markers of haemophilic arthropathy, and in providing objective insight into the efficacy of new therapies. In acute haemarthrosis, arthrocentesis expedites recovery and prevent the vicious cycle of bleed-synovitis-rebleed. When synovial proliferation develops, a multidisciplinary team approach is critical with haematology, orthopaedics, and physiotherapy involvement. Synovectomy is considered for patients with chronic synovitis that fail conservative management. Non-surgical and minimally invasive procedures should always be offered and considered first. Careful patient selection, screening and early intervention increase the success of these interventions in reducing bleeding, pain, and improving joint function and quality of life. Chemical synovectomy is practical in developing countries, but radioactive synovectomy appears to be more effective. When surgical synovectomy is considered, arthroscopic/minimally invasive approach should be attempted first. In advanced haemophilic arthropathy, joint replacement and arthrodesis can be considered. While excited about the future of haemophilia management, navigating musculoskeletal challenges in the aging haemophilia population is equally important.

Stromal cell-derived factor 1 alpha (SDF-1alfa) and cartilage oligomeric matrix protein (COMP): Two potential signature biomarkers of radiological detectable hemophilic arthropathy

INTRODUCTION

Hemophilia is a rare constitutional bleeding disorder due to a deficiency in Factor VIII or Factor IX. Recurrent hemarthroses, one of the major complications of the disease, lead to hemophilic arthropathy, a disabling condition that requires early diagnosis. Traditionally, clinical examination and plain film radiography have been used to diagnose hemophilic arthropathy. Magnetic resonance imaging (MRI) and ultrasound can be more useful for diagnosing soft-tissue changes. However, but each of these methods has limitations and diagnosis of arthropathy can be delayed.

AIM

The aim of this project was to assess plasmatic biomolecules indicative of osteo-cartilaginous damage in patients with hemophilia with or without known arthropathy, in order to improve the diagnosis of this major complication of the disease.

METHODS

In this monocentric retrospective study, 40 patients with hemophilia A or B, for whom a plasma sample was available, provided informed consent for further analyses (multiplex immunoassays and ELISA) and collection of relevant clinical information in their medical files. Correlations were sought for between biomarkers of interest and the severity of joint lesions assessed according to Pettersson's radiologic score.

RESULTS

Two biomarkers were identified, respectively SDF-1α and COMP. Their plasmatic levels were significantly increased in patients with arthropathy compared to controls and patients without arthropathy. These values correlated significantly with the Pettersson score in patients under regular prophylaxis.

CONCLUSION

Two plasma biomarkers have been identified that could help assess the presence and severity of hemophilic arthropathy.

Foam roller-based self-induced myofascial therapy in patients with hemophilic knee arthropathy: a multicenter, single-blind, randomized clinical study

BACKGROUND

Hemophilia is a congenital coagulopathy characterized by degenerative joint damage. Self-induced myofascial therapy aims to decrease pain and improve tissue mobility, functionality and proprioception.

AIM

The aim of this study was to evaluate the safety and efficacy of self-induced myofascial release in patients with hemophilic knee arthropathy.

DESIGN

This is a randomized clinical study.

SETTING

This study was carried out in different patient associations.

POPULATION

Fifty-two patients with hemophilia were included in the study.

METHODS

Patients were randomized to the experimental group (daily home protocol of foam roller-based self-induced myofascial therapy for 8 weeks) or the control group (no intervention). The variables were the frequency of hemarthrosis (self-reporting), pain intensity (visual analog scale), range of motion (goniometry) and muscle strength (dynamometry). All variables were evaluated at baseline, post-treatment and after a 10-week follow-up.

RESULTS

The patients included in the experimental group showed significant improvements in terms of a decrease in frequency of hemarthrosis (mean difference [MD]=-0.61; 95% confidence interval [CI]: -0.81; -0.41) and pain intensity (MD=-0.33; 95% CI: -0.48, -0.18), increased range of motion (MD=0.88; 95% CI: 0.39; 1.37), strength in quadriceps (MD=0.88; 95% CI: 0.39; 1.37). (MD=12.39; 95% CI: 3.44; 21.34) and hamstrings (MD=7.85; 95% CI: 0.60; 15.11). There were intergroup differences in the frequency of hemarthrosis (F=14.51; P<0.001), pain intensity (F=9.14; P<0.001) and range of motion (F=13.58; P<0.001).

CONCLUSIONS

Self-induced myofascial therapy can be an effective complementary technique in the treatment of patients with hemophilic arthropathy. Self-induced myofascial therapy can reduce the frequency of knee hemarthrosis in patients with hemophilia. This technique can improve pain intensity and range of motion in patients with hemophilic knee arthropathy.

CLINICAL REHABILITATION IMPACT

Hemophilic knee arthropathy is characterized by chronic pain, decreased range of motion, and periarticular muscle atrophy. Foam roller-based self-induced myofascial therapy can reduce the frequency of hemarthrosis and pain intensity and improve range of motion in patients with hemophilic arthropathy. Foam roller-based self-induced myofascial therapy is safe and effective in the treatment of patients with hemophilia. The inclusion of self-induced myofascial therapy exercises in the approach to degenerative joint pathologies may be an effective and safe treatment option.