Effectiveness of Physiotherapy in the Treatment of Hemophilic Arthropathy a Systematic Review

Special Article - Hemophilia

Ann Hematol Oncol. 2017; 4(9): 1172.

Effectiveness of Physiotherapy in the Treatment of Hemophilic Arthropathy a Systematic Review

Cuesta-Barriuso R*

Department of Physiotherapy, European University of Madrid, Royal Victoria Eugenia Foundation, Spain

*Corresponding author: Cuesta-Barriuso R, Department of Physiotherapy, European University of Madrid, Royal Victoria Eugenia Foundation, Spain

Received: July 10, 2017; Accepted: August 21, 2017; Published: October 12, 2017


Hemophilia is a congenital coagulopathy characterized by musculoskeletal bleeding. The recurrence of bleeding in one joint causes joint deterioration known as hemophilic arthropathy. This arthropathy is characterized by chronic pain, and loss of joint mobility, muscle strength and proprioception. Prophylactic medical treatment with physiotherapy may improve the physical conditions of patients with hemophilia.

Method: A systematic search was conducted in PubMed, Science Direct, Isi Web and the specialized journal Haemophilia. The information on the intervention, control condition, study methodology and the main findings of each study were extracted and summarized critically. The methodological quality of the selected studies was evaluated using the Van Tulder and PEDro scales.

Results: Data from 10 studies fulfilled the selection criteria. Physiotherapy programs through home exercise programs and ergonomic bicycle and treadmill exercises to develop muscle strength, gait and proprioception produced significant improvements in pain perception, joint range of motion and muscle strength. Similarly, manual therapy is safe and effective in improving chronic pain and joint mobility. Finally, educational physiotherapy improves the perception of pain and the quality of patients with hemophilia. The results were less clear for social perception and attributional bias. The overall methodological quality of the study was medium-high. The power of the results, through the size of the effect was medium-high.

Conclusion: Physiotherapy interventions through educational physiotherapy, manual therapy, stretching, muscle strength protocols and cycling exercises improve pain perception, functionality, proprioception and muscle strength, and quality of life and perception of disease in patients with hemophilic arthropathy.

Keywords: Hemophilia; Joint damage; Hemophilic arthropathy; Physiotherapy; Randomized clinical trial


Hemophilia is a hereditary and recessive disease, linked to the X chromosome, characterized by the deficiency of one of the clotting factors. Based on the deficit factor, there two types of hemophilia: A (FVIII deficit factor) and B (IX deficit factor), and depending on the percentage in blood of FVIII/FIX, hemophilia severity varies (severe: <1%, moderate: 1-5%, and mild: >5%) [1]. The prevalence of the disease is 1: 5000 live births in hemophilia A and 1: 30000 live births in hemophilia B [2].

This hematological disease is characterized by hemorrhages in the locomotor system, mainly located in muscles and joints (haemarthrosis) [3]. Joint bleeding mainly occurs in knees, ankles and elbows [4]. Repeated haemarthrosis in the same joint leads to the development of synovial membrane hypertrophy, chemical and enzymatic intra articular alterations, and finally joint degeneration (hemophilic arthropathy) [5].

The onset of arthropathy presents with radiological alterations (decreased joint interline, bone deformity, and the development of osteophytes, among others), physical alterations (chronic pain, loss of range of motion and periarticular muscle strength, and altered proprioception) [6], as well as psychological alterations (decreased perception of quality of life) [7].

The Gold standard in the treatment of hemophilia is the periodic intravenous administration of the lacking clotting factor (prophylactic treatment) [8]. This therapeutic model has been shown to be the most effective in the prevention of hemorrhages and the development of hemophilic arthropathy. However, despite advances in medical treatments, adult patients and those living in developing countries have not had access to prophylaxis, thus exhibiting significant joint alterations [9].

When the joint has developed a degenerative arthropathy the therapeutic options include physiotherapeutic and orthopedic treatment with the aim of improving functionality [10]. An appropriate management of the hemophilia patient’s chronic pain is essential, requiring the participation of physiotherapists in the multidisciplinary team treating patients with hemophilia [11]. Although a number of studies have been designed to assess the safety and efficacy of the various physiotherapy techniques such as electrotherapy [12], strength and proprioception training [13], and aqua fitness training [14], further progress is needed identify and design a protocol for the physiotherapeutic approach in patients with hemophilic arthropathy. Conducting studies with a good methodological design that evaluate the safety and efficacy of well-defined protocols is fundamental for the generalized use of physiotherapy in patients with hemophilia [15].

The present study aims to carry out a systematic review of the treatment of physiotherapy in an approach to patients with hemophilic arthropathy.


Study design

Systematic review carried out in May and June 2017.

Documentary sources

This review was prepared using the databases Science Direct, Isi Web and Medline. Haemophilia, specializing in research on patients with congenital coagulopathies, was also consulted.

Search strategy

The search strategy devised to locate the articles related to our object of study was: (haemophilia OR hemophilia) AND (physical therapy OR physiotherapy) and arthropathy) in the title, abstract and keywords.

Article selection criteria

No limit was placed on the year of publication of the articles or the language of publication in the search process.

The criteria for inclusion of the articles in this review were: published articles; describing the technique of physiotherapy used with duly identified measuring instruments; being a randomized clinical trial (RCT); and patients should be diagnosed with hemophilic arthropathy in one of the joints.

We excluded from the review those studies that were: studies in which patients followed programs of non-therapeutic exercise; and abstracts or Congress communications.

Qualitative analysis of the level of scientific evidence

In order to carry out the qualitative analysis of the level of scientific evidence of the selected articles, two scales were used: Van Tulder [16] and PEDro [17].

The Van Tulder scale analyzes the threats to the validity of randomized clinical trials based on the elements of adequacy of the random method, concealment of treatment placement, low vision and intention-to-treat analysis, using 11 items. The Physiotherapyspecific PEDro scale was developed to be used in experimental studies and provides an important source of information to support practice based on clinical evidence evaluating the internal validity and presentation of the statistical analysis of the studies, using 10 items. The presence of quality indicators scores 1 point, while no quality indicators score 0 points.

Quantitative analysis of selected studies

An analysis was carried out to obtain the main descriptive statistics (mean and standard deviation) of the methodological variables of the treatment and of the patients recruited in the articles analyzed.

Similarly, using the Rosenthal formula [18], the effect size of the results obtained with respect to the different study variables was calculated.


Search results

As a result of the search process, 183 articles were identified. In a first phase, after discarding the 116 articles repeated among the various documentary sources, the titles and abstract of the remaining 67 studies were analyzed. Finally, following the selection process, only 10 articles [19-28] met the established criteria. Figure 1 shows the flow diagram with the selection made according to the criteria described above.