PHYSIOTHERAPY

MANAGEMENT IN
H E M AT O L O G I C A L D I S O R D E R

HEMOPHILIA
• Haemophilia is a congenital X-linked bleeding disorder in which
blood does not properly clot
• It is categorized as a disorder of homeostasis.
• Deficient clotting is due to an abnormality of the functional plasma-
clotting proteins, factors VIII and IX, that are involved in this
process.
• Injuries and surgeries can cause bleeding episodes in individuals
with haemophilia. Most also experience episodes of spontaneous
bleeding.
• In regard to bleeding, they do not bleed any faster than the average
person, but they do bleed for a longer period of time.
• Haemophilia is a blood-clotting disorder caused by a deficiency in
factor VIII or factor IX.
• Joint bleeding is common feature and make patient disable if
untreated.
• Physiotherapy is evidence based medical treatment to keep patient
active.
• Physiotherapy should be applied cautiously in case of haemophilia
patient. In order to achieve good result physiotherapist have to
know about details of haemophilia
MILD HEMOPHILIA

• 25% of cases
-Spontaneous haemorrhages are rare
-Deep muscle and joint bleeding are uncommon
-Injury, trauma, surgery, and dental injury trigger bleeding
-these symptoms are addressed the same as with individual
with severe haemophilia.
MODERATE HEMOPHILIA

• 15% of cases
• Spontaneous hemorrhages are usually not an issue
• Minor trauma can result in major bleeding incidences
SEVERE HEMOPHILIA

• 60% of cases
• Spontaneous bleeding
• Slight trauma may precipitate bleeding into deep muscle
and joints
CLINICAL SIGNS AND SYMPTOMS

• The most common presentation of haemophilia is hemarthrosis, in

which bleeding occurs inside joint spaces.
• The occurrence of joint bleeds increases as a baby begins to walk;
these episodes can vary in severity, from swelling with mild pain to
extremely swollen with severe pain. The joint most commonly
affected is the knee “followed by the ankle, elbow, hip, shoulder, and
wrist
 ACUTE HEMARTHROSIS SYMPTOMS
INCLUDE
• swelling
• pain
• heat around joint
• tenderness
• decreased motion
• tingling, aura, or prickling sensation
• stiffening into the position that is comfortable (usually
flexion)
• If there are recurrent episodes of hemarthrosis,
haemophiliac joint disease may develop. This disease can
lead to further symptoms such as:
• progressive decreased motion
• flexion contractures
• muscle atrophy
• The second most common presentation of hemophilia is muscle
hemorrhage, where bleeding occurs into muscles. A muscle
hemorrhage can be massive and more insidious.
• They commonly occur in muscles that flex such as the
gastrocnemius, iliopsoas, and the forearm flexor surface. The
symptoms presenting with muscle hemorrhage can include:
• gradually intensifying pain
• loss of sensation
• decreased motion at surrounding joints
• muscle assuming comfortable position (usually shortened)
• protective muscle spasms
PT INTERVENTION
• Acute Stage: pain present at rest and with all activity
• RICE (ice for 10-20 minutes every 1-2 hours: see
Cryotherapy Guidelines) • Immobilize / Splint •
NWB with appropriate assistive device
 SUBACUTE STAGE:
• Continue RICE prn for pain and after exertion
• Splinting, resting splint for protection at night, weaning splint
as able with pain as guide •
• Wean assistive device and begin progressive weight bearing
• Activity modification to avoid pain • Pain-free gentle AROM of
affected joint
• Pain-free progressive strengthening of affected and unaffected
joint
CHRONIC STAGE: PAIN-FREE WITH ADLS
• Dynamic splinting to increase ROM prn
• Progressive active/passive ROM to affected joint
• Progressive Strengthening: Open chain, closed chain, resistive band and
proprioceptive training to affected joint
• Gentle joint mobilizations to increase ROM
• Modified functional activities and sports to avoid aggravation of
symptoms
• Orthotics or possible casting for chronic issues
• Conditioning to address other areas of impairment
• Education regarding precautions to prevent re-injury/re-bleeds or injury
OTHER TREATMENT CONSIDERATIONS
• TENS
• Electrical Stimulation
• Relaxation Techniques for muscle guarding
• Kinesiology tape
• Cryotherapy (see Cryotherapy Guidelines)
• Elastic stockinette Joint support for return to sports
• Appropriate treatment if associated sprain/injury
• Myofascial release

• Further consultation with medical team

• Work with haematologist for adequate factor coverage

• Further imaging (plain radiographs to determine joint status,

MRI to determine the presence of chronic synovitis)

• Treatment duration will vary based on individual needs and may

require a longer duration than those identified for individuals
without bleeding disorders.
PRECAUTIONS/CONTRAINDICATIONS

• Avoid aggressive exercise and activity

• Increasing activity too early
• Monitor for nerve compression
• No return to sport/activity until pain-free full ROM
and strength