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Balance, P roprioception and the Aging H emophilia P opulation

Great Plains Regional Hemophilia Providers Meeting. Balance, P roprioception and the Aging H emophilia P opulation. Bruno UK Steiner, PT,MT The Anatomical Works 4/24/12. HIV HCV. https://www2a.cdc.gov/ncbddd/htcweb/UDC_Report. People with Hemophilia are maturing.

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Balance, P roprioception and the Aging H emophilia P opulation

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  1. Great Plains Regional Hemophilia Providers Meeting Balance, Proprioception and the Aging Hemophilia Population Bruno UK Steiner, PT,MT The Anatomical Works 4/24/12

  2. HIV HCV

  3. https://www2a.cdc.gov/ncbddd/htcweb/UDC_Report

  4. People with Hemophilia are maturing • They will gradually exhibit challenges and diseases of aging that we all ultimately face whether they are orthopedic, neurological, circulatory, organic. • In some cases, the challenges will be greater for the Person with hemophilia ie. greater incidence of osteoporosis, arthritic changes. • A greater incidence of falls, which can be catastrophic for this clientele

  5. Hemarthrosis (Joint Bleeding) • Most common site of bleeding • Most frequently affected joints: • Knees, elbows and ankles • Target joint • Repeated bleeding in the same joint Shoulder 8% Elbow 25% Hip 5% Knees 44% Ankle 15% Hemophilic Arthropathy Source: World Federation of Hemophilia. Facts and Figures Monograph Series. 1998.

  6. End-stage joint arthropathy • Destruction of cartilage • Narrowing joint space • Subchondral cysts • Collapse and sclerosis

  7. Hemophilic arthropathy might be similar to osteoarthritis Valentino, JTH, 2000 • Important implication for a community PT (we know how to treat OA) • Both result in • Structural and functional failure of synovial joints • Loss and erosion of articular cartilage • Alteration of subchondral bone • Synovial inflammation • Pain and disability • Severe decrease in ROM, strength, function • And….

  8. Deterioration of joint position sense • deterioratedproprioception and balance in: • standing, • walking • positional transfers

  9. Proprioception • Is the body’s sense/awareness of position and movement • It is how our CNS monitors movement and coordinates postural/motion adjustment • Involves peripheral mechanoreceptors: which sense deformational, velocity and positional change in joint and related tissues • Relays info to the cerebellum and cerebral cortex for further processing

  10. Proprioceptive Mechanoreceptors • Nerve endings which are part of the PNS • Provide continuous afferent flow of nerve impulses to the CNS (Cerebellum, Thalamus, Cortex via the spinal cord) • Classified Type I, II, III, IV • Described in many tissues of the locomotor system: Cruciate and Collateral ligaments, Menisci, Joint capsules, Tendons, Tendon Sheaths, and Aponeurosis. McCray, 2005

  11. Proprioceptive Mechanoreceptors • Located in joint structures • Located in muscle to transduce stretch of the muscle • Located cutaneously

  12. Type I Mechanoreceptor: Ruffini’s Corpuscle • Located in the deep layers of the skin, ligaments, joint structures • Registers mechanical deformation within joints, angle change, withspecificity of up to 2 degrees

  13. Type II Mechanoreceptor: Pacinian Corpuscle • Thought to respond to high velocity changes in joint position. • found in skin and joint structures

  14. Type III Mechanoreceptor: • Golgi Tendon Organ • Neurotendinous stretch receptors • Helps regulate the force of muscle contractions • Monitors muscle force through the entire physiological range of motion • Affects the timing of the transitions between the stance and swing phases of walking

  15. Type IV Mechanoreceptors: Free Nerve Endings

  16. Dorsal Spinocerebellar Tract • Mechanoreceptors conveys proprioceptive information to the cerebellum for further coordination and processing

  17. Dorsal Column-Medial Lemniscal Pathway Information from Mechanoreceptors are transmitted to the Medulla Oblongata From M.O. to the Thalamus and ultimately relayed to the Cerebral Cortex

  18. Hemarthrosis • Knees >50% of bleeds • Elbow, ankles, shoulders, wrists

  19. Intra-articular bleeding

  20. Muscle Bleeding Signs and Symptoms Vague ache or pain Heat Swelling Inability/unwillingness to move muscle Tightness of skin Source: Butler . Basic Concepts of Hemophilia 2001; 3; 12.

  21. Courtesy Ollie Edmunds MD

  22. Courtesy Ollie Edmunds MD

  23. Courtesy Ollie Edmunds MD

  24. Courtesy Ollie Edmunds MD

  25. Courtesy Ollie Edmunds MD

  26. Courtesy Ollie Edmunds MD

  27. Deterioration of Joint Position Sense Skinner, Barrack, J ElectromyogrKinesiol 1991 Sep;1(3):180-90 • Joint position sense in the normal and pathological knee joint: Conclusions • Structural damage (ACL disruption, arthritis,total knee replacement) as well as aging cause deterioration of Joint position sense • Total knee replacement and arthritic change cause the greatest deterioration • Reconstruction of ligamentous structures and/or rehabilitation appears to restore joint position sense to a near normal level

  28. Furthermore aging appears to decrease the number of mechanoreceptors responsible for proprioceptionor joint position sense • Decrease in the number of mechanoreceptors in rabbit ACL: the effects of aging. Aydog, Korkusuz et al, Knee SurgTraumatolArthrosc 2006 April • Researchers conclude that aging results in both diminished numbers and changed morphology of mechanoreceptors

  29. Balance dysfunctions in adults with HaemophiliaFearn, Hill et al, Haemophilia(2010) • 20 PWH and 20 controls (mean age 39.4) • Impairment of balance in PWH compared with controls • Recommendations made: • “clinicians should include assessments of balance and related measures when reviewing adults with haemophilia.”

  30. Why does this all matter? A decrease in proprioception increases the risk of falls in People with Hemophilia

  31. A Fall can have a big impact on the lifestyle of a PWH • Often require immobilization and factor product • Sometimes hospitalization • Sometimes a permanent reduction in their mobility • Furthermore, fear of falling can limit confidence and restrict lifestyle choices Fearn, Hill et al. Haemophilia2010

  32. Fall Preventionis where Physical Therapists can have a great impact in the management of PWH

  33. The Physical Therapist’s Role Acute versus sub-acute management and treatment

  34. The Acute Patient • RICE, clotting factor • Focus on damage containment, decreasing swelling, pain, tissue tension • Assess nerve entrapment, compartment syndromes and neurovascular compromise • Loading a bleeding joint results in progressive joint damage • Must prevent continued synovial membrane microtrauma and mechanical impingement (can result in repeated bleeding) Mulvany, 2003

  35. Sub-Acute/Chronic Rehabilitation • Treatment must be individualized to meet the patients needs… • The patient may need to infuse pre-therapy to reduce bleed risk • Must focus on fall prevention!

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