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PHYSIOTHERAPY AND
HEMOPHILIA
Nairobi, Kenya
June 26, 2013
OBJECTIVES
• Describe the goals of physiotherapy in the treatment of
hemophilia
• Review the concept and application of PRIICE
• Outline splinting and immobilization techniques
• Examine principles of rehabilitation
• Highlight the importance of sports and physical activity
• Provide advice for already compromised joints and
muscles due to previous bleeding episodes
INTRODUCTION
• Physiotherapy is integral in the management of people
with hemophilia
• A key goal is to help maintain mobility, muscle strength,
and balance
• If these have been compromised , physiotherapy must
restore or improve these modalities
• Physiotherapy advises on safe sports and exercises
ROLE OF PHYSIOTHERAPY
Physiotherapy plays a vital role in the prevention/ minimizing of
deformities and disabilities associated with hemophilia
and facilitates a normal functional lifestyle.
ROLE OF PHYSIOTHERAPY (CONT’D)
Physiotherapy aims to:
• Educate people with hemophilia and their families
• Advise patients about the importance of joint protection
• Advise on treatment for pain and suffering
• Regularly assess and monitor joint status
• Work as part of the multidisciplinary team to determine
treatment modalities
GOALS OF PHYSIOTHERAPY
• Treatment of muscle imbalances
• Ensure ↓ of pain and ↑ of function
• Stretching to improve flexibility and prevent muscle
shortening
• Prevent and correct muscle imbalances
• Strengthening of muscles to improve stability
• Posture training
• Correction of wrong/harmful movement patterns and
joint biomechanics to prevent damage
• Treatment of affected/badly-functioning joints
ACUTE PHASE: P-R-I-I-C-E PRINCIPLE
• P
Protection of the affected muscle or joint
• R
Replace the missing clotting factor
•
I
Immobilize using a splint in the neutral position
•
I
Ice
• C
Compression with a bandage
• E
Elevation of the area that is bleeding
P-R-I-I-C-E PRINCIPLE
Protect - Why?
• To reduce pain
• Minimize risk of causing another bleed
• The joint is at its highest risk of re-injury in the first 2
weeks
• The muscle is at its highest risk of re-injury in the first 6
weeks
Replacement
• Factor first if available
P-R-I-I-C-E PRINCIPLE (CONT’D)
Immobilize: How?
• NWB (Non weight bearing) of the affected limb
• Use crutches and splints
• Backslab (should be light), thermal plaster, static splint
• Splint in a comfortable position and comfortable ROM (range
of motion)
• Bed rest in cases of iliopsoas bleeds
• Refer to OT if available
• No sports
• Move only within pain-free range
P-R-I-I-C-E PRINCIPLE (CONT’D)
Immobilize: How long?
• Until signs and symptoms are much better
• Until full and easy pain-free ROM (range of motion) is
restored
• For major bleeds, 3-5 days at most
• Immobilize for short periods at a time
• Immobilize during strenuous parts of the day, e.g., at school
during the break periods when boys play
• The longer you immobilize, the greater the muscle weakness,
loss of proprioception, and risk of re-bleed when the cast
removed
P-R-I-I-C-E PRINCIPLE (CONT’D)
Ice: Treatment protocol
• Ice the affected area
• 5 mins on, 10 mins off
• Place the ice circumferentially around the area
• Do not place the ice directly on the
skin. Use a towel or cloth as a barrier
between skin and ice
• Use ice after exercise
P-R-I-I-C-E PRINCIPLE (CONT’D)
Compression
• Slows bleeding
• Reduces swelling
• Reduces pain
• Limits movement of the joint
• Use crepe bandages or tubigrip/orthogrip
• Not too tight because it may cause more damage
P-R-I-I-C-E PRINCIPLE (CONT’D)
Elevation
• Not to be used in acute phase, as too painful
• Reinforces rest
• Assists in drainage - reduces swelling
REHABILITATION
When bleeding has stopped…
• After controlling acute bleeds
• Joints /muscles need to return to pre-bleed state
• Pre-bleed state/phase depends on severity of bleed and
length of rest/immobilization
• Target joints are less likely to return to pre-bleed state
REHABILITATION
During acute stage (joint bleed)
• Start with gentle static muscle contraction (static exercises)
when pain allows
• This can commence while the area is still bleeding
• 5-10 contractions twice a day
• Progress to 15 contractions at least 3 times per day when
pain decreases and swelling is down
REHABILITATION
During acute stage (cont’d)
• As symptoms improve by 50%,
progress to free active exercises
• Start with pain-free range and
progress slowly
• Fewer repetitions to start
• Gradually progress to more
repetition, up to 15 counts
• Thereafter progress to heavier
resistance/weight (with lower reps
again to start)
REHABILITATION
ROM (range of motion)
• Active stretching exercise
• Hold-relax stretching after immobilization phase
• Progress to contract-relax stretching
• Hold the stretch for 10 -15 seconds
• Serial splint can be used for prolonged stretching
REHABILITATION
Stretches
• Be careful, because over stretching can lead to muscle
bleed
• Active stretch is the best
• Passive gentle stretch until full stretch
• Serial splint for prolonged stretching (in case of joint
contracture)
REHABILITATION
Strength
• Muscles are weaker after immobilization and rest, some
become wasted
• Isometric (static) muscle contraction from acute stage
• Progress slowly to free active exercises: inner range
exercises, movement with gravity eliminated, movement
against gravity
REHABILITATION
• Resisted exercise to commence when the ROM is at least
90% (too much resistance can cause bleed)
• When Full ROM is achieved, add light weights, less
repetition (5-10), progress to 15 repetitions 3 times per day
• Gradual return to activities/ sport
• REMEMBER: Strong muscles support and protect the joint,
which reduces the risk of bleeding
REHABILITATION
Proprioception
• Is a sense of posture, movement and change in equilibrium,
and knowledge of position, weight, and resistance
• Very important to restore because it is good for dynamic
balance
• One-leg-stand test, with eyes open and closed
• Walking on uneven surface, hopping, skipping and stairs
climbing
REHABILITATION
Weight bearing status
•
NWB (non weight bearing) during acute stage with crutches,
splint
Progress to..
•
PWB (partial weight bearing) with crutches, with splint on only
during start of free active exercises
Progress to…
•
FWB (full Weight Bearing) with crutches and splint on
•
FWB with crutches, splint off
•
FWB, without any aid and normal gait (when full ROM, good
muscle strength achieved)
PHYSICAL ACTIVITIES AND SPORT
Why?
• Physical, psychosocial and social benefits
• Protects the joint by building strong muscles and healthy
ligaments
• Improves skills, coordination, endurance/stamina
• Fosters team spirit, friendship, and gives a child a sense of
personal achievement.
• Helps restore full activity
PHYSICAL ACTIVITIES AND SPORT
Which sports?
• Avoid contact sports, high impact sports or sports with a
very high risk of bleeds: boxing, soccer/football, rugby,
hockey, mountain biking, squash, weightlifting
• Appropriate sports will depend on the bleeding profile of the
PWH (predominantly LL or UL bleeders?)
• Suitable sports: swimming, cycling, walking, dancing,
rowing
SUMMARY
• Physiotherapy is an important part of hemophilia care
• The healing process will occur with good rehabilitation
techniques and is a slow process
• Working in a team with the physiotherapist and
comprehensive care team is advantageous to the
PWH
• Proprioception needs to be worked on for every bleed
• Exercise programs will be better adhered to if we set
achievable, age-appropriate goals
• EXERCISES ARE MOST IMPORTANT
REFERENCES
•
Exercises for People with Hemophilia, WFH 2006
•
South African Practical Guidelines for Physiotherapy in
Haemophilia. Editorial committee on behalf of the SAHF
MASAC, national working group on physiotherapy
MERGER AVEC SLIDE 1
ANNE-LOUISE CRUIKSHANK
Haemophilia Nurse Coordinator
Western Cape South Africa
Original authors:
Tshifhiwa Mukheli, Chris Hani Baragwaneth Hospital, Johannesburg
Henriette Tredoux, Universitas Hospital Bloemfontein
Revised and collated by:
Anne Gillham, April 2013
Sameer Rahim, Red Cross War Memorial Children’s Hospital,
Cape Town, May 2013