Identifying performance-based outcome measures of physical function in people with haemophilia (IPOP).

INTRODUCTION: Recent recommendations of core outcome sets for haemophilia highlight the need for including measures of performance-based physical health and physical function sustainability. To date, there is no consensus on what outcomes might be of value to clinicians and patients. AIM: To identify instruments of performance-based physical function to monitor musculoskeletal health in people with haemophilia that are practical in the clinical setting. METHODS: Utilising components from the Activities and Participation Category of the WHO International Classification of Functioning (WHO-ICF), a consensus-based, decision analysis approach was used to: identify activities people with haemophilia have most difficulty performing; identify quantitative performance-based measures of identified activities via a scoping review; and obtain views on acceptability of the tests utilising a DELPHI approach. RESULTS: Eleven activities were identified: maintaining a standing position, walking long distances, walking up and down stairs, walking on different surfaces, running, hopping, jumping, squatting, kneeling, undertaking a complex lower limb task, undertaking a complex upper limb task. Following a 2-round DELPHI survey of international physiotherapists, the 6-min walk test, timed up and down stairs, 30-s sit to stand, single leg stance, tandem stance, single hop for distance (children only) and timed up and go (adults only) reached consensus. CONCLUSION: This study is the first step in defining a core set of performance-based instruments to monitor physical health and sustainability of physical function outcomes in people with haemophilia. Establishing the psychometric properties of the instruments and whether they are meaningful to people with haemophilia is essential.

Developing clinical practice guidelines for physiotherapists working with people with inherited bleeding disorders.

INTRODUCTION: Several bleeding disorders are characterized by haemorrhage into joints and muscles. These conditions are best managed by interdisciplinary teams that include physiotherapists. In 1997, physiotherapists from haemophilia treatment centres in Canada formed the Canadian Physiotherapists in Hemophilia Care (CPHC). The guiding principles of the CPHC reflect a commitment to evidence-based practice, education and collaboration. AIM: To describe the process used by CPHC to develop evidence-based clinical practice guidelines to inform best practice, guide decision-making and help educate physiotherapists, students, and other team members about the physiotherapy management of people with bleeding disorders. METHODS: We followed the procedures outlined in the American Physical Therapy Association's Clinical Practice Guideline Process Manual (2018). Namely, we selected a working group, determined the scope of the guidelines, performed a literature search, selected and appraised the evidence, drafted the guidelines as practice statements, assigned a strength of recommendation to each practice statement and disseminated the guidelines. RESULTS: Thirty-nine practice statements were developed in nine practice areas. Strength of evidence was strong for two statements, moderate for one and weak for three. The remainder were graded as theoretical or best practice. CONCLUSION: To our knowledge, these are the first evidence-based clinical practice guidelines that cover all aspects of physiotherapy management of people with bleeding disorders. Some areas, such as exercise and manual therapy, have been well investigated. However, the overall low levels of evidence and low strengths of recommendations highlight the need for more rigorous research with this population.

Exercise for haemophilia.

BACKGROUND: Haemophilia is a bleeding disorder associated with haemorrhaging into joints and muscles. Exercise is often used to aid recovery after bleeds, and to improve joint function in the presence of arthropathy. OBJECTIVES: Our objective was to systematically review the available evidence on the safety and effectiveness of exercise for people with haemophilia. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register and electronic databases PubMed, OVID-Embase, and CINAHL. We hand searched abstracts from congresses of the World Federation of Hemophilia and the European Hematology Association, trial registries and the reference lists of relevant articles.Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register: 14 December 2016. SELECTION CRITERIA: Randomized or quasi-randomized controlled studies comparing any exercise intervention considered relevant in haemophilia management including supervised, unsupervised, aquatic, strengthening, aerobic or cardiovascular, stretching, proprioceptive and balance training exercise programs in males of any age with haemophilia A or B of any severity (those with co-morbidities were not excluded). DATA COLLECTION AND ANALYSIS: Two authors reviewed the identified abstracts to determine their eligibility. For studies meeting the inclusion criteria, full articles were obtained. The two authors extracted data and assessed the risk of bias. Any disagreements were resolved by discussion. The authors contacted study investigators to obtain any missing data. MAIN RESULTS: Eight studies were included, which represented 233 males with all severities of haemophilia A and B, ranging in age from eight years to 49 years. Study duration ranged from four to 12 weeks. Exercise interventions varied greatly and included resistance exercises, isometric exercises, bicycle ergometry, treadmill walking and hydrotherapy; therefore, comparison between studies was difficult.None of the studies measured or reported adverse effects from the interventions. None of the studies reported outcomes regarding bleed frequency, quality of life or aerobic activity. Overall risk of bias across all studies was assessed as unclear.Very few studies provided sufficient information for comparison. None of the studies reported data that favoured the control group. One study reported that six weeks of resistance training improved joint health status (Colorado score) compared to controls. The addition of pulsed electromagnetic fields also improved ankle scores compared to exercises alone, but this was not seen in the elbows or knees.Two studies reported statistically significant improvements in pain intensity after exercise interventions compared to controls. Hydrotherapy exercises produced significant decreases in pain compared to controls and land-based exercise groups.Two studies found improvement in joint motion in the exercise group compared to controls. One study compared land- and water-based exercises; there was no difference in the range of motion between the two groups; however, the water-based exercise group did show improvement over the control group.One study, comparing joint traction and proprioceptive neuromuscular facilitation for the elbow to a control group, showed no differences in biceps girth or strength after 12 weeks of intervention.Some studies reported comparisons between interventions. In one study, treadmill training significantly improved balance in children compared to bicycle ergometry. Another study added partial weight bearing exercises to quadriceps exercises and showed improved walking tolerance.Four studies evaluated quadriceps or hamstring strength (or both). The addition of bicycle ergometry and exercises with weights was more effective than static exercises and treadmill walking for strengthening knee flexors and extensors. Partial weight-bearing exercises through range were more effective than static and short arc exercises for improving knee extensor strength. The addition of treadmill walking to ultrasound, stretching and strengthening exercises showed increased peak torque of knee flexors and extensors and decrease in knee effusion.The results should be interpreted with caution due to the quality of evidence (GRADE) as outlined in the summary of findings tables, which demonstrates that all but one of the outcomes assessed were rated as low or very low due to the small sample sizes and potential bias. AUTHORS' CONCLUSIONS: These results must be considered with caution. There is a lack of confidence in the results due to the small number of included studies and the inability to pool the results due to the heterogeneity of outcome measures. Most exercise interventions produced improvement in one or more of the measured outcomes including pain, range of motion, strength and walking tolerance. Hydrotherapy may be more effective than land exercises for pain relief in adults. Functional exercises such as treadmill walking and partial weight bearing exercises seem to be more effective than static or short arc exercises for improving muscle strength. These findings are consistent with the many non-controlled intervention reports in the haemophilia literature. No adverse effects were reported as a result of any of the interventions. However, some groups used prophylactic factor prior to exercise and other groups studied only subjects with moderate haemophilia. Therefore, the safety of these techniques for persons with severe haemophilia remains unclear.

Physiotherapist performed Point of Care Ultrasonography (POCUS): a scoping review of 209 studies.

BACKGROUND: Point of care ultrasonography (POCUS) is a non-ionizing imaging technique that is emerging in physiotherapy practice. OBJECTIVE: To systematically map the research literature on physiotherapist performed POCUS. DATA SOURCES: Following PRISMA-ScR guidelines, OVID Medline, CINAHL, AMED, and EMBASE were searched. ELIGIBILITY CRITERIA: Peer-reviewed publications of physiotherapist performed POCUS were included. DATA EXTRACTION AND DATA SYNTHESIS: Data collected included: title, author(s), journal, year of publication, design of included studies, sample size, age category of the sample, anatomical area of POCUS, geographical location of research, study setting, and disease condition/patient population. Data analysis consisted of descriptive statistics for the key characteristics of each research question. RESULTS: A total of 18 217 titles and abstracts and 1 372 full-text citations were screened, with 209 studies included. Most included studies were measurement studies that assessed the psychometric properties of POCUS in adult patients, were published in the United States of America and imaged the abdominal lumbo-pelvic region. Eighty-two percent of studies were published in the last 10 years. LIMITATIONS: Non-English language, review articles and grey literature were excluded for feasibility. Studies were excluded if it was not clearly reported that a physiotherapist performed the POCUS. CONCLUSION: This review identified a wide variety of practice settings and a diverse number of patient conditions in which physiotherapists are performing POCUS. This breadth and depth of this review highlighted the need for improved reporting of study methodology and key areas of future research in physiotherapy performed POCUS. CONTRIBUTION OF THE PAPER.

Scoping Review of Curricula and Pedagogical Approaches for Physiotherapist Performed Point of Care Ultrasonography.

Purpose: This study collates and maps physiotherapy pre- and post-licensure curricula and pedagogical approaches for point of care ultrasonography (POCUS). Method: We used a standardized scoping review methodology and reporting framework. A total of 18,217 titles and abstracts, and 1,372 full text citations were screened, with 209 studies classified as physiotherapist performed POCUS. Results: Of the 209 studies, 15 evaluated pre- and post-licensure curricula and pedagogical approaches. Seventy-two to 98% of pre-licensure programs reported including theoretical knowledge of POCUS and 44-45% reported practical teaching or competency assessment. In post-licensure studies of POCUS, 0-61% of physiotherapists reported training for POCUS. All studies of post-licensure pedagogical approaches included an assessment of theoretical knowledge of POCUS, but only one study included a practical assessment of competency. There was considerable variability in POCUS methods and duration of pedagogical approaches. Except for one study, all pedagogical approaches reported improvement in theoretical knowledge. Conclusion: Progress in physiotherapy-specific, standardized, competency-based curricula and pedagogical approaches in POCUS has been limited, with minimal research available, and considerable variability both pre- and post-licensure. These findings could be used to advocate for the inclusion of POCUS in pre- and post-licensure physiotherapy curriculum, and suggest a need for clear guidelines from regulatory colleges and licensing bodies, and a common terminology for physiotherapist performed POCUS. Future directions for research include a systematic review of the psychometric properties of physiotherapist performed POCUS within and across anatomical areas, an assessment of value of different forms of training, and an evaluation of the impact of physiotherapist performed POCUS on patient outcomes.

Objectif: compiler et cartographier les programmes et les approches pédagogiques avant et après l'obtention du permis d'exercer à l'égard de l'échographie au point d'intervention (ÉPI). Méthodologie: analyse environnementale standardisée et cadre référentiel. Les chercheurs ont examiné un total de 18 217 titres et résumés et de 1 372 citations complètes, et 209 études ont été classées comme des ÉPI effectuées par des physiothérapeutes. Résultats: des 209 études, 15 évaluaient des programmes et des approches pédagogiques avant et après l'obtention du permis d'exercer. De 72 % à 98 % des programmes avant l'obtention du permis d'exercer présentaient des connaissances théoriques sur l'ÉPI, et de 44 % à 45 % traitaient de l'enseignement pratique ou de l'évaluation des compétences. Pour ce qui est des études sur l'ÉPI après l'obtention du permis d'exercer, de 0 % à 61 % des physiothérapeutes ont déclaré avoir suivi une formation sur l'ÉPI. Toutes les études sur les approches pédagogiques après l'obtention du permis d'exercer contenaient une évaluation des connaissances théoriques sur l'ÉPI, mais une seule incluait une évaluation pratique de la compétence. Les modes d'ÉPI et la durée des approches pédagogiques étaient très variables. Sauf dans une étude, toutes les approches pédagogiques entraînaient une amélioration des connaissances théoriques. Conclusion: les programmes et approches pédagogiques des ÉPI fondés sur les compétences, standardisés et propres à la physiothérapie ont peu évolué, on fait l'objet de très peu de recherches et sont très variables tant avant et qu'après l'obtention du permis d'exercer. Ces résultats pourraient être utilisés pour revendiquer l'inclusion des ÉPI dans les programmes de physiothérapie avant et après l'obtention du permis d'exercer et démontrent la nécessité de directives claires de la part des ordres de réglementation et des organismes d'attribution de permis, de même que d'une terminologie commune sur les ÉPI effectuées par des physiothérapeutes. Les futures orientations de la recherche comprennent une analyse systématique des propriétés psychométriques des ÉPI effectuées par un physiothérapeute dans les zones anatomiques et entre elles, une évaluation de la valeur de divers types de formation et une évaluation des effets des ÉPI effectuées par des physiothérapeutes sur les résultats cliniques des patients.

Multidisciplinary Team Care of Patients with Hemophilic Arthropathy: A Qualitative Assessment of Contemporary Practice in the UK and Canada : Canada/UK: MDT Practices for Hemophilia.

We used a structured interview to explore approaches to comprehensive hemophilia and arthropathy care among 24 healthcare professionals (HCPs) from multidisciplinary teams (MDTs) in Canada and the UK. Represented MDTs typically comprise a hematologist, nurse, physiotherapist, and sometimes an orthopedic surgeon; pediatric (and some adult) MDTs also include a social worker/psychologist. HCPs emphasized the centrality of a team approach, facilitated through MDT meetings and involvement of all MDT members in patient care. In both countries, nurses and physiotherapists play critical, multifaceted roles. Respondents agreed that MDTs are crucial for successful transitioning, which can be facilitated by close collaboration between pediatric and adult MDTs, even when they are not co-located. Physiotherapists are instrumental in providing non-pharmacological pain relief. Hematologists or physiotherapists typically make orthopedic referrals, with the nurse, physiotherapist and hematologist working together in patient preparation for (and follow-up after) surgery. MDT best practices include a non-hierarchical team approach, ensuring that all MDT members know all patients, and regular MDT meetings. Together, these real-life insights from the MDT perspective emphasize the value of the MDT approach in comprehensive hemophilia care.

Musculoskeletal ultrasound in hemophilia: Results and recommendations from a global survey and consensus meeting.

INTRODUCTION: For persons with hemophilia, optimization of joint outcomes is an important unmet need. The aim of this initiative was to determine use of ultrasound in evaluating arthropathy in persons with hemophilia, and to move toward consensus among hemophilia care providers regarding the preferred ultrasound protocols for global adaptation. METHODS: A global survey of hemophilia treatment centers was conducted that focused on understanding how and why ultrasound was being used and endeavored to move toward consensus definitions of both point-of-care musculoskeletal ultrasound (POC-MSKUS) and full diagnostic ultrasound, terminology to describe structures being assessed by ultrasound, and how these assessments should be interpreted. Next, an in-person meeting of an international group of hemophilia health care professionals and patient representatives was held, with the objective of achieving consensus regarding the acquisition and interpretation of POC-MSKUS and full diagnostic ultrasound for use in the assessment of musculoskeletal (MSK) pathologies in persons with hemophilia. RESULTS: The recommendations were that clear definitions of the types of ultrasound examinations should be adopted and that a standardized ultrasound scoring/measurement system should be developed, tested, and implemented. The scoring/measurement system should be tiered to allow for a range of complexity yet maintain the ability for comparison across levels. CONCLUSION: Ultrasound is an evolving technology increasingly used for the assessment of MSK outcomes in persons with hemophilia. As adoption increases globally for clinical care and research, it will become increasingly important to establish clear guidelines for image acquisition, interpretation, and reporting to ensure accuracy, consistency, and comparability across groups.