Physiotherapy and hemophilia

1. Physiotherapy and hemophilia Nairobi, Kenya June 26, 2013

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Rehabilitation During acute stage (joint bleed) Startwith 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

16. 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)

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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

27. Merger avec slide 1 Anne-louise CruikshankHaemophilia Nurse CoordinatorWestern Cape South Africa Original authors: TshifhiwaMukheli, Chris Hani Baragwaneth Hospital, Johannesburg HenrietteTredoux, Universitas Hospital Bloemfontein Revised and collated by: Anne Gillham, April 2013 Sameer Rahim, Red Cross War Memorial Children’s Hospital, Cape Town, May 2013