Hemophilia is a bleeding disorder caused by abnormal plasma-clotting proteins. Clients with hemophilia have prolonged bleeding times and the risk of internal hemorrhaging into joints and muscles. This disorder is classified by the client's percentage of clotting factors: mild is 5% to 50%; moderate is 1% to 5%; severe is <1%. Patients with moderate and severe hemophilia will need factor replacement therapy to control and prevent excessive bleeding. Individuals with hemophilia may develop limited endurance from a combination of factors that include repeated joint bleeds, pain and limited joint mobility, muscle atrophy, and fear of injury. Limited endurance is associated with decreased muscle strength, joint stability, and proprioception.1,2
Comorbidities to Consider
Keys to Examination of Clients
The stages of joint degeneration secondary to joint bleeds are determined by radiographs of joints using the Arnold-Hilgartner and Pettersson scales.3
Discuss with clients if they have developed "target joints" from repeated bleeding episodes, which will need to be assessed carefully for mobility and signs of synovitis.
Arnold-Hilgartner Criteria for Stages of Hemophilic Arthropathy
1: Soft-tissue swelling, no skeletal abnormalities
2: Osteopenia and overgrowth of epiphysis, normal joint space
3: Changes in osseous contours, formation of chondral cysts
4: Narrowing of joint space, signs of articular cartilage destructions
5: Substantial disorganization of joint structures
Recommended Baseline Testing of Fitness Levels
Aerobic fitness testing can be performed with walking or cycle ergometry methods.4,5
Assess for client risk of falling and the ability to control movements without risking overstressing joints and muscle groups.
Client may need to take clotting factor replacement therapy before engaging in testing and new exercise programs.6
Type: Recreational and fitness activities4
Intensity: Moderate intensities, 60%–80% of peak heart rate.
Frequency: Three to five times per week
Individuals with hemophilia need to choose safe and appropriate activities that will not place them at risk for recurrent joint and muscle bleeds.4 Young people can be encouraged to participate in recreational and competitive swimming as these activities pose minimal risk for bleeding episodes, provide social interactions, and can be performed for a lifetime.2 Some young people with hemophilia may rebel against restrictions on their participation in sports and recreational activities.5
Resistive exercise should be started at low levels with an emphasis on endurance activities of 15 to 20 repetitions. The client's movements and technique should be closely monitored to ensure good joint stability and control of the motion. The exercises should avoid excessive eccentric muscle loading so as to prevent micro-traumas that could lead to muscle bleeds.6 Clients may need a referral to a physical therapist after a significant bleed to regain normal motion and to develop a plan for returning to ...