Presentation on theme: "Balance, Proprioception and the Aging Hemophilia Population"— Presentation transcript:
1 Balance, Proprioception and the Aging Hemophilia Population Great Plains Regional Hemophilia Providers MeetingBalance, Proprioception and the Aging Hemophilia PopulationBruno UK Steiner, PT,MTThe Anatomical Works4/24/12
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 bleedingMost frequently affected joints:Knees, elbows and anklesTarget jointRepeated bleeding in the same jointShoulder 8%Elbow 25%Hip 5%Speaker’s Notes:Hemarthrosis is bleeding into a joint.Joint bleeding is the most common type of bleeding episode. The most commonly affected joints are the knees, elbows, and ankles but bleeding can occur in shoulders, hips, wrists or any other joint in the body. A target joint is repeated bleeding into a joint and often leads to hemophilic arthropathy.Knees 44%Hemophilic ArthropathyAnkle 15%Source: World Federation of Hemophilia. Facts and Figures Monograph Series
6 End-stage joint arthropathy Destruction of cartilageNarrowing joint spaceSubchondral cystsCollapse 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 inStructural and functional failure of synovial jointsLoss and erosion of articular cartilageAlteration of subchondral boneSynovial inflammationPain and disabilitySevere decrease in ROM, strength, functionAnd….
8 Deterioration of joint position sense deteriorated proprioception and balance in:standing,walkingpositional transfers
9 Proprioception Is the body’s sense/awareness of position and movement It is how our CNS monitors movement and coordinates postural/motion adjustmentInvolves peripheral mechanoreceptors: which sense deformational, velocity and positional change in joint and related tissuesRelays info to the cerebellum and cerebral cortex for further processing
10 Proprioceptive Mechanoreceptors Nerve endings which are part of the PNSProvide continuous afferent flow of nerve impulses to the CNS (Cerebellum, Thalamus, Cortex via the spinal cord)Classified Type I, II, III, IVDescribed 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 structuresLocated in muscle to transduce stretch of the muscleLocated cutaneously
14 Type I Mechanoreceptor: Ruffini’s Corpuscle Located in the deep layers of the skin, ligaments, joint structuresRegisters mechanical deformation within joints, angle change, with specificity of up to 2 degrees
15 Type II Mechanoreceptor: Pacinian Corpuscle Thought to respond to high velocity changes in joint position.found in skin and joint structures
16 Type III Mechanoreceptor: Golgi Tendon OrganNeurotendinous stretch receptorsHelps regulate the force of muscle contractionsMonitors muscle force through the entire physiological range of motionAffects the timing of the transitions between the stance and swing phases of walking
35 Muscle Bleeding Signs and Symptoms Vague ache or pain Heat Swelling Inability/unwillingness to move muscleTightness of skinSpeaker’s Notes:Muscle bleeding is the second most frequent site of bleeding.Any area of the body can be affected but frequently the extremities are involved. Large muscle bleeding can lead to nerve compression (i.e. iliopsoas, thigh - see picture). Significant blood loss can occur in large muscles before appreciable swelling is evident. Therefore, it is important to monitor hemogloblin levels.Bleeding into small muscles can also cause compartment syndrome (i.e. forearm, calf).Signs and symptoms of muscle bleeding may include:Vague ache or painHeatSwellingInability/unwillingness to move muscleTightness of skinSource: Butler . Basic Concepts of Hemophilia 2001; 3; 12.
42 Deterioration of Joint Position Sense Skinner, Barrack, J Electromyogr Kinesiol 1991 Sep;1(3):180-90 Joint position sense in the normal and pathological knee joint: ConclusionsStructural damage (ACL disruption, arthritis,total knee replacement) as well as aging cause deterioration of Joint position senseTotal knee replacement and arthritic change cause the greatest deteriorationReconstruction of ligamentous structures and/or rehabilitation appears to restore joint position sense to a near normal level
43 Furthermore aging appears to decrease the number of mechanoreceptors responsible for proprioception or joint position senseDecrease in the number of mechanoreceptors in rabbit ACL: the effects of aging.Aydog, Korkusuz et al, Knee Surg Traumatol Arthrosc 2006 AprilResearchers conclude that aging results in both diminished numbers and changed morphology of mechanoreceptors
44 20 PWH and 20 controls (mean age 39.4) Balance dysfunctions in adults with Haemophilia Fearn, Hill et al, Haemophilia (2010)20 PWH and 20 controls (mean age 39.4)Impairment of balance in PWH compared with controlsRecommendations made:“clinicians should include assessments of balance and related measures when reviewing adults with haemophilia.”
45 A decrease in proprioception Why does this all matter?A decrease in proprioceptionincreases the risk of falls in People with Hemophilia
46 A Fall can have a big impact on the lifestyle of a PWH Often require immobilization and factor productSometimes hospitalizationSometimes a permanent reduction in their mobilityFurthermore, fear of falling can limit confidence and restrict lifestyle choicesFearn, Hill et al. Haemophilia 2010
47 Fall Prevention is where Physical Therapists can have a great impact in the management of PWH
48 The Physical Therapist’s Role Acute versus sub-acute management and treatment
49 The Acute Patient RICE, clotting factor Focus on damage containment, decreasing swelling, pain, tissue tensionAssess nerve entrapment, compartment syndromes and neurovascular compromiseLoading a bleeding joint results in progressive joint damageMust prevent continued synovial membrane microtrauma and mechanical impingement (can result in repeated bleeding)Mulvany, 2003
50 Sub-Acute/Chronic Rehabilitation Treatment must be individualized to meet the patients needs…The patient may need to infuse pre-therapy to reduce bleed riskMust focus on fall prevention!
51 PTs need to Assess: Strength, ROM of the affected extremity Resultant joint hypomobility/stiffnessassess whether due to joint deformity, joint or myofascial contractureBalance/proprioception in standing as well as gaitFunction/Transfers:sit to stand, stand to sit, bed mobility
52 PT Assessment cont’dGet a sense of the patient’s joint/ tissue irritability to guide the treatment approach and intensityTreatment should progress as per patient’s tolerance levels (pain and muscle fatigue must be considered in tailoring any exercise regimen)Assess use of Gait assistive devices
53 PT Sub-acute/chronic treatment Soft tissue mobilizationJoint mobilizationStretchingCastingSplintingResistance trainingLow impact, mid range (avoidance of extremes of range, and explosive movt’s)Orthotics and assistive devices/wheeled mobility
54 Proprioceptive Re-education Balancing exercisesFunctional transfersSingle leg standing progression to greater levels of difficulty and balance duration
55 Benefits of Resistive and Proprioceptive Training Importance of resistance training for haemophilia patients1increasing muscle strengthdecreasing the frequency and severity of bleeding episodes and associated painTailored home exercise program targeting balance, strengthening and walking2positive physical outcomes including improved balance and mobility1Tiktinsky et al Haemophilia 2002Hill,2Fearn et al Haemophilia 2010
56 But balance training has to be ongoing Evidence of detraining after 12-week home-based exercise programs designed to reduce fall risk factors in older people recently discharged from hospital Vogler et al Arch Phys Med Rehabil 2012 April 11Conclude that balance improvements and fall risk reductions associated with the program were partially to totally lost after cessation of the interventionThese significant detraining effects suggest that sustained adherence to falls prevention exercise programs is required to reduce fall risk
57 Proprioception as a Way of Life for the Maturing Hemophilia Population Should have exercise session at least twice a weekShould be a lifelong practiceYou don’t use it, you lose itThis goes for the entire aging population, not just for PWH.
58 Physical activity and exercise Increase joint circulationNutrition to articular cartilageStrengthen musclesImprove joint stabilityPreserve/improve joint function and ROMWeight loss/maintenanceRelieved pressure on weight bearing joints
59 Role of Exercise and Physical Activity on Hemophilic Arthropathy Various exercises include:Aerobic exerciseWalkingAquatic/swimmingBikingStrength/resistance trainingMay stabilize jointsImproved walking ability, disability and pain in elderly with OA (FAST study)Isometric trainingBalance and flexibilityStretching (tai chi, yoga)Improved flexibility of muscles and tendons around affected jointsEases painImproves balanceForsyth et al. Haemophilia 2011
60 Recommended Activities Low impact, mid range (avoidance of extremes of range)SwimmingResistance trainingTai chi (or Tai Chi like): a martial art with profound benefits
61 Tai Chi Using all muscles/joints (big and small) Using smooth motion with wide range of motion but no hyperextensionIsometric, concentric and eccentric exercisesNever incorporates extreme movementsthere will be no stresses or strains causing hemarthroses or muscle bleedsSmooth, slow, gradual loading and unloading of joint and muscle: no explosive movt’sA truly choreographed neurophysiological workout
62 Group and home-based tai chi in elderly subjects with knee osteoarthritis Randomized clinical trial41 adults (70 +/- 9.2 years) with knee osteoarthritis6 weeks of group tai chi sessions (40 min) TIW, followed by another 6 weeks of home-based tai chi trainingSignificant improvements inmean overall knee pain (P = )maximum knee pain (P = )physical function (P = )stiffness (P = ) compared to the baselineBrismee et al. Clin Rehabil. 2007
64 A Word on Gait Assistive Devices: Use of Cane A cane should be used with the hand on the opposing side of the affected knee/ankle- with right knee/ankle arthropathy, use cane in the left hand- right heel strike should accompany left cane strikeCane height should be measured to the crease of the wrist… consider use of bicycle glove if pressure is an issue.… There are always exceptions!
65 Exceptions: Use of Canes Case 1.- Right sided LE arthropathy (knee/ankle) and left sided UE arthropathy (elbow/shoulder)- Which side for the cane?Case 2.- Patient has right sided knee OA and uses the cane on his right. When trying to train the use on his left, his balance and use of the cane is precarious at best.- What do you do?
66 Maybe Assess the use of a Roller Walker Handle height should be to the crease of the wrist.Typically, people have them a little or much too high, resulting in shoulder and elbow pain.Appropriate ambulatory assistive devices should be considered proprioceptive training equipment
67 Adaptive/assistive considerations Consult Occupational TherapyUse of different bath grab bar configurations following a balance perturbationGuitard, Sveistrup et al Ottawa, Canada, Assist Technol 2011 Winter;23(4):205-15Vertically oriented bars appear to be favoredRecommends use of vertical grab bars in the bath to promote safetyAdditional bars may be needed to ensure safety during stand to sit and sit to stand phases of bath transfer.
68 Cautionary notes/suggestions for the multidisciplinary Team Communicate with community PT (provide insight and information for this special clientele)Verify whether your patient is engaged in balance training program, encourage these types of activityPT care should be individualized.Ideally, the therapist should not work on too many patients at once.
69 Manual Physical Therapy Specific gently administered soft tissue manipulation and joint mobilizationEffective for contractures and marked myofascial and joint tightnessMay progress clients to greater muscle and connective tissue length. Moderate improvement in ROM may improve function and pain considerably.
70 Other considerationsThe importance of a good working relationship between therapist and clientConsultation with PT for other orthopedic conditions that normally crop upSI, spinal, myofascial pain and strains/sprains nerve root irritation etc.If need be, patient may benefit and progress with a change in therapist