Catherine Pollard is Advanced Physiotherapy Clinician for Haemophilia Auckland/North Land Region, New Zealand
Research has shown that after bleeding episodes there are subtle joint changes that cause alterations in patterns of walking. This can occur even in young children with haemophilia. Increasing our awareness of this and ensuring proper assessment and rehabilitation following a joint bleed may minimise these changes and reduce the risk of further bleeding episodes and damage.
When a joint bleed occurs, blood starts to leak into the joint space. Blood is not normally present inside the joint and the presence of even a small amount can produce lasting damage to the joint. When the bleed has stopped and the blood is removed from the joint, the pain eases and range of motion returns. Once this has occurred it is easy to presume that the joint is back to normal.
However, research of walking patterns in haemophilia has demonstrated that even in young children, bleeding episodes early in life can produce subtle changes in how the joints and muscles work to produce movement.(5) For example, when comparing boys with haemophilia to boys the same age but with no health concerns, there were differences noted in how the muscles surrounding the ankle and knee are activated. Boys with haemophilia also had less movement in their hips, knees and ankles and tended to walk with their knees slightly bent.(2–4,8) These small changes in how the joints move can increase strain on muscles, ligaments and cartilage and increase the loading pressures through the joint. Ultimately this may leave the joint more vulnerable to structural overloading and synovial pinching, with the increased risk of further bleeding episodes and damage.(7)
For best management at the present time a specialist haemophilia physiotherapist can provide advice and support to recover from a bleeding episode quickly and rehabilitate the muscles and joint back to optimal function. Physiotherapists are trained to observe walking patterns and joint movements and can identify factors which may leave a joint more vulnerable to future bleeding episodes, as well as teach you how to help reduce these risks.
A new approach being explored is the development of three-dimensional gait analysis. This utilises multiple video cameras pointed at different angles to record a person walking, and has made it possible to identify small changes in joints and muscles. Three-dimensional gait analysis provides information to clinical staff that would be undetectable just by watching the child during normal functional activities.(1) This could prove to be very useful as it may take years before the resulting damage shows up on X-ray or through clinical examination. Three-dimensional gait analysis is not yet widely available in Australia or New Zealand but may be in the future.
If you are unsure who your local haemophilia physiotherapist is, please contact your Haemophilia Centre for advice.
1.Bladen M, Alderson L, Khair K, et al. Can early subclinical gait changes in children with haemophilia be identified using the GAITRite walkway. Haemophilia 2007;13(5):542-47. doi:10.1111/j.1365-2516.2007.01429.x
2.Cayir A, Yavuzer G, Sayli RT, et al. Evaluation of joint findings with gait analysis in children with hemophilia. Journal of Back and Musculoskeletal Rehabilitation 2014;27(3): 307-13. doi: 10.3233/BMR-130448.
3.Lobet S, Detrembleur C, Francq B, et al. Natural progression of blood-induced joint damage in patients with haemophilia: clinical relevance and reproducibility of three-dimensional gait analysis. Haemophilia 2010;16(5), 813-21. doi:10.1111/j.1365-2516.2010.02245.x
4.Lobet S, Detrembleur C, Massaad F, et al. Three-dimensional gait analysis can shed new light on walking in patients with haemophilia. The Scientific World Journal 2013; 2013:1-7. doi:10.1155/2013/284358
5.Manco-Johnson M J, Manco-Johnson ML, Jacobson L, et al. Prophylaxis versus episodic teatment to prevent joint disease in boys with severe hemophilia. The New England Journal of Medicine 2007;357(6):535-544. doi:10.1056/NEJMoa067659
6.Roosendaal G, Van Der Berg HM, Lafeber FP et al. Blood-induced joint damage: an overview of musculoskeletal research in haemophilia. In: Rodriguez-Merchan EC, Goddard NJ, Lee CA, eds. Musculoskeletal aspects of haemophilia. Oxford: Blackwell Science, 2000.
8.Stephensen D, Drechsler W, Winter M, et al. Comparison of biomechanical gait parameters of young children with haemophilia and those of age-matched peers. Haemophilia 2009;15(2), 509-518. doi:10.1111/j.1365-2516.2008.01934.x
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