Aims of Physiotherapy
The maintenance of healthy joints and muscles is crucial to the quality of life of a PWH. Clotting factor replacement may stop or even prevent bleeds but it does not restore joint or muscle function. Only regular movement and exercise can do that.
Physiotherapy aims to bring relief from pain, restore muscle power and control, restore range of joint movement and prevent further injury to a target joint. A well maintained body shrugs off everyday stresses and strains and repairs itself far more quickly than a body that has been neglected.
The task of the physiotherapist working in a hemophilia care center is three fold
- To encourage maintenance of health
- To teach people how to prevent problems occurring in the first place; and
- To speed repair when things go wrong.
An initial full assessment of the bleed is required by the physiotherapist who will record the cause of injury, site and size of injury and range of movement. Appropriate therapy should be administered immediately at home or by hospital staff. This then should be followed by the golden rule of first aid namely, rest, ice, compression and elevation, (RICE, to be short). How each of these should be administered is explained as follows:
Rest
The appropriate part should be rested for the first 24 hours. For lower limb problems, crutches may be required for support. A sling may be required for upper limb problems. Thereafter, gentle movements should be encouraged within the limits of pain.
Ice
Ice packs can help to reduce pain and swelling. A frozen bag of peas wrapped in a damp towel and applied for 10 minutes may relieve pain. Ice . |
|
should not be used if there is any loss of sensation or if the circulation of blood is poor. Ice should not also be applied directly to the skin as it can result in ice burn
Compression
Support to the area with Tubigrip or bandage or splinting can relieve pain and reduce swelling. This should be applied in the morning before getting up. It is important to ensure that Tubigrip is not too tight and does not restrict circulation. Tubigrip should be removed at night.
Elevation
The lower limb should be elevated when sitting, to help minimize swelling. Standing for long periods should be avoided. A sling for the upper limb will help to reduce swelling in the hand.After RICE for 2-3 days, repeated assessment should be made to evaluate the recovery process to look out for any untoward complications. A decrease in swelling and a rapid recovery of muscle function would indicate a superficial haematoma. Progression of treatment should be gradual and based on clinical findings. Each patient must be treated individually as no two haemorrhages respond in the same way.
In the plan of treatment, various physiotherapy modalities may be used as an adjunct to exercise programmes, such as
|
a) Ultrasound therapy It is particularly useful at a later stage in the rehabilitation programme for muscle haematomas when there is clear evidence that acute bleeding has stopped. This may be 3-4 days or even longer.
(b) Pulsed short-wave diathermy (PSWD) : This is often the treatment of choice for early bleeding episodes. PSWD machines do no emit a continuous beam of energy and therefore no heat is transmitted to the affected area. This is very important as increase in blood flow would not be beneficial following acute injury. |
(c) Deep frictional massage It is a specific technique applied to muscles, which aims to maintain and restore the normal mobility of the affected structures. This treatment should be given with caution by a qualified and experienced physiotherapist in the later stages of rehabilitation programme.
Role Of Physiotherapy In The Management Of Hemophilia
A physiotherapist has an excellent knowledge of how the muscles and joints of the body work and move together. They are trained to treat injuries that occur to these structures, as well as observe abnormalities of posture or walking. A physiotherapist can improve a muscle's strength and length, and help increase the flexibility of joints, and reduce pain and swelling and injury. A physiotherapist can help to provide the optimum environment for healing to occur following an injury and can help structures to heal in the right way, so that weak areas or deformities do not develop and normal function is restored.
Although physiotherapists have guidelines for treatment they know that no two people are the same. Each patient is individually assessed and then course of exercise is provided appropriately. So also any advice and treatment, all tailored to the specific needs. When there is a bleed the first and foremost thing is to treat with factor replacement therapy.
This will stop the bleeding, but it does not remove the accumulated blood, which can cause damage to the muscle or joint. A physiotherapist will try to minimize the chances of any lasting damage to muscle or joint following a bleed. Firstly they can reduce the pain and swelling and then they can help to restore the lost movement and strength. It is not always possible to get to the hemophilia centre immediately after a bleed but the physiotherapist can still give advice on things to do at home to speed up recovery. If there are several bleeds then also the physiotherapist can help by working with the patient to strengthen the muscles surrounding the joint and improve the balance and flexibility. This can help to break the bleeding cycle and limit the chances of further bleeds and damage.
Repeated bleeds into a joint can result in permanent changes, which are characterized by pain, stiffness and weakness in the joint, and poor mobility. This is a particular type of arthritis experienced only by persons with hemophilia and is known as chronic haemophilic arthropathy.
Children and teenagers who have been on prophylaxis from a young age are unlikely to experience this damage to joints, as spontaneous bleeds should not have occurred, but it can be apparent in older boys and adults. A physiotherapist can not reverse these changes once they are established, but he can ease the symptoms associated with such changes. They can give ideas on how to make day-to-day activities easier at home, work, or school, or provide equipment to support a weak, painful or badly damaged joint.The physiotherapist can explain the process of joint damage to a patient so that he/she can tell the difference between bleeding and arthritis, and prescribe proper exercises to keep the joints mobile and muscles strong.
When there is a severe joint damage and surgery such as knee replacement is indicated the physiotherapist will be involved in the rehabilitation process. Before surgery he can suggest exercises to strengthen the muscle. After the operation he will help the patient move again with appropriate exercise and activities and will ensure that the patient gets the most out of the operation.
Owing to their knowledge of the musculoskeletal system the physiotherapists can identify incorrect posture or a bad back. These problems in a haemphiliac need to be taken as seriously as bleeding episode because if they are left untreated a weak area can develop which will precipitate further injury.
Physiotherapists with their knowledge of the body and what is involved when playing different sports, can advise a person with hemophilia about which sports are safe and what precautions are to be taken.
