Pediatric Rheumatology Online Journal → August 2003 → Miscellaneous Clinical Studies and Case Reports → Abstract #196

REHABILITATIVE PHYSIOTHERAPY AND INTRA-ARTICULAR STEROIDS IN THE MANAGEMENT OF HAEMOPHILIC ARTHROPATHY

N. M. R. Wilkinson,¹ M. Bladen,² K. Khair,² R. Leisner,² P. Woo.¹

¹Paediatric Rheumatology, Great Ormond Street Hospital, London, United Kingdom; ²Paediatric Haematology, Great Ormond Street Hospital, London, United Kingdom

Introduction Haemarthropathy remains a significant cause of morbidity in haemophiliacs. Management includes coagulation factors, rest and physiotherapy. Those with inhibitors to factor VIII (FVIII) or IX (FIX) require recombinant factor VIIa (rVIIa), costing [pound>532/mg. The management of juvenile idiopathic arthritis includes rehabilitative physiotherapy and intra-articular steroids. We have used this same combination in 3 boys with haemophilia and arthropathy.
Methods Three boys, aged 9-12 years, two with haemophilia A and one with haemophilia B had chronic synovitis confirmed by MRI. With appropriate factor replacement, each received a week of intensive physiotherapy and intraarticular Triamcinolone. Clinical and therapeutic data were assessed retrospectively from the preceding and following six months.
Results Each boy responded well with fewer bleeds and improved joint function. Case 1 had a FVIII inhibitor and had had 10 bleeds in either of 2 joints prior to intervention, requiring 10.8mg rVIIa per bleed. There were no subsequent bleeds in the joints injected. This coincided with complete eradication of the inhibitor yet there was a bleed in an uninjected joint. Case 2 had a FIX inhibitor and had had 2-4 bleeds per month in one of four joints prior to injection, for which he received 7.2mg rVIIa per bleed. There were fewer bleeds in the injected joints over the following 2 months, but not in the joint omitted from injection due to an acute bleed. A subsequent major increase in reported bleeds and rVIIa use was eventually attributed to a pscychological cause. School was missed following each bleed. Case 3 had developed arthropathy due to inadequate propyhlaxis. Intervention reduced the number of bleeds from 2-4 to 0-1 per month and improved the range of joint movement and gait. There was no school absenteeism.
Conclusion Clinical benefit and cost savings have been identified with this approach, but further research is required to establish its use and identify any long-term benefit.