¿Efectividad de la técnica de liberación miofacial en el aumento del rango articular en restricción glenohumeral? Una comparación con la kinesioterapia tradicional / Effectiveness of the myofascial release technique in increasing joint range in glenohumeral restriction? A comparison with traditional kinesiotherapy

OBJETIVO: comparar la kinesioterapia tradicional con la técnica miofacial en pacientes con restricción articular interna glenohumeral. MÉTODO: estudio comparativo de 8 pacientes en un grupo de intervención (GI) y kinésico (GC), durante 8 semanas. Se comparó el pre y post test del ROM interno glenohumeral en ambos grupos mediante t de student. RESULTADOS: el grupo de la técnica miofascial demostró una amento significativo de ROM interno glenohumeral de 15,2º (p < 0,001), mientras que el grupo control no fue significativo (p > 0,05) sólo de de 6,4º. CONCLUSIONES:Un tratamiento de terapia con la Técnicas Liberación Miofascial en pacientes con déficit rotacional interno de hombro es más eficaz para aumentar el rango de movimiento articular de rotación interna glenohumeral que una técnica tradicional y conservadora.

OBJETIVE: to compare traditional kinesiotherapy with myofacial technique in patients with glenohumeral internal joint restriction. METHODS: comparative study of 8 patients in an intervention (IG) and kinesiotherapy (CG) group for 8 weeks. The pre- and post-test of glenohumeral internal ROM in both groups was compared using Student's t-test. RESULTS: the myofascial technique group showed a significant increase in glenohumeral internal ROM of 15.2º (p < 0.001), while the control group was not significant (p > 0.05) only 6.4º. CONCLUSIONS: A therapy treatment with Myofascial Release Techniques in patients with shoulder internal rotational deficit is more effective in increasing glenohumeral internal rotational joint range of motion than a traditional, conservative technique.

Evaluación de resultados del tratamiento aplicado a adultos mayores con entidades del SOMA en Sala de Rehabilitación Integral / Evaluation of the results of the treatment applied to older adults with OMAS entities in the Comprehensive Rehabilitation Room

RESUMEN Introducción: el paciente anciano está expuesto a múltiples problemáticas con el envejecimiento que van a condicionar en gran manera su independencia y que de forma obligatoria hay que conocer y tratar de solucionar. Objetivo: evaluar el resultado del tratamiento aplicado a adultos mayores con entidades del sistema osteomioarticular en sala de rehabilitación integral. Materiales y Métodos: se realizó un estudio observacional, descriptivo, de tipo longitudinal de los todos los pacientes de 60 y más años, que acudieron al Centro de rehabilitación integral, quedando la muestra constituida por 920 pacientes tratados en el período comprendido entre enero y diciembre de 2007 con enfermedades del Soma. Resultados: predominó el sexo femenino (59 %) en el grupo de edades de 60 a 69 años (48%). Las afecciones ortopédicas fueron las más frecuentes con el 64 % y dentro de estas, la periartritis escapulo humeral. La electroterapia fue el tratamiento más utilizado (38,4%) de los casos. Dentro de los síntomas que presentaron estos pacientes el que más frecuente se encontró fue el de alteraciones en las funciones tanto al inicio y como posterior al tratamiento aplicado. El 93% de los pacientes resultaron rehabilitados, siendo el 86 % los evaluados de excelente al final de tratamiento aplicado. Conclusiones: los resultados en la atención al adulto mayor fueron excelentes en la gran mayoría de los casos con la aplicación del tratamiento rehabilitador (AU).

SUMMARY Introduction: the elder patient is exposed to multiple problems with ageing that will greatly condition their independence and that we will necessarily have to know and try to solve, using all the available resources within our reach. Objective: to assess the result of the treatment applied to older adults with entities of the osteomyoarticular system in the comprehensive rehabilitation room. Materials and methods: an observational, descriptive, longitudinal study of all the patients aged 60 years and over who attended the Comprehensive Rehabilitation Center was carried out, intentionally the sample stayed formed by 920 patients treated in the period between January and December 2007 with diseases of the OMAS. Results: female sex predominated (59%) in the age group of 60 to 69 years (48%). Orthopedic conditions were the most frequent with 64% and within these, scapular-humeral periarthritis. Electrotherapy was the most used treatment (38.4% of the cases). Among the symptoms that these patients presented, the most frequently found was alterations in functions both at the beginning and after the treatment applied. 93 % of the patients were rehabilitated, resulting outstanding 86 % of the assessed patients at the end pf the treatment. Conclusions: the results of elder people care was outstanding in most of the cases with the rehabilitative treatment application (AU).

[Clinical research for rehabilitation training combined with modified shu-acupuncture for joint dysfunction after meniscal suture surgery].

OBJECTIVE: To compare the effects on joint dysfunction after meniscal suture surgery between rehabilitation training combined with modified shu-acupuncture and simple rehabilitation training. METHODS: Seventy-one patients with meniscal suture surgery were randomized into an observation group (n=36) and a control group (n=35). Patients in the observation group received modified shu-acupuncture combined with rehabilitation training. Acupuncture for 8 weeks were at Zutonggu (BL 65), Shugu (BL 66), Neiting (ST 44), Xiangu (ST 43), Xiaxi (GB 43), Zulinqi (GB 41), Dadu (SP 2), Taibai (SP 3), Xingjian (LR 2), and Taichong (LR 3), once a day for continuous 6 days with 1 day for rest. Patients in the control group received simple rehabilitation training for continuous 8 weeks. The training included quadriceps femoris, range of knee joint motion and motion and limb walking on the affected side. The effect score for meniscus injury after treatment from Japanese Orthopaedics Association (JOA) and visual analogue scale (VAS) score were recorded before and after treatment. The effects were compared in the two groups. RESULTS: After treatment, the VAS and JOA scores were improved in the two groups (all P<0.05), with better results in the observation group (both P<0.05). The effective rate was 91.7% (33/36) in the observation group, which was better than 80.0% (28/35) in the control group (P<0.05). CONCLUSION: Rehabilitation training combined with shu-acupuncture achieve better effect than simple rehabilitation training for joint dysfunction after meniscal suture surgery.

Manipulation Under Anesthesia: A Safe and Effective Treatment for Posttraumatic Arthrofibrosis of the Knee.

OBJECTIVES: This study investigates the results of closed manipulations performed under anesthesia (MUA) to evaluate whether it is an effective means to treat posttraumatic knee arthrofibrosis. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Twenty-two patients with a mean age of 40 underwent closed MUA for posttraumatic knee arthrofibrosis. Injuries included fractures of the femur, tibia, and patella as well as ligamentous injuries and traumatic arthrotomies. The mean time from treatment to manipulation was 90 days. Mean follow-up after manipulation was 7 months. INTERVENTION: Closed knee MUA. OUTCOME MEASUREMENTS: Improvement of knee range of motion (ROM) arc was the primary outcome. Patient demographics were correlated with manipulation success using a 2-sample t test. A delay in manipulation of 90 days or greater was also evaluated in this fashion with regard to its role in predicting the benefit of MUA. RESULTS: The mean premanipulation ROM arc was 59 ± 25 degrees. The mean intraoperative arc of motion, achieved at the time of the manipulation was 123 ± 14 degrees. No complications occurred during the MUA procedure. At the most recent follow-up, the mean ROM arc was 110 ± 19 degrees. Tobacco use, associated injuries, elevated body mass index, open fracture, and advanced age did not impact manipulation efficacy. Additionally, manipulations performed 90 days or more after surgical treatment provided a benefit equaling those performed more acutely (P = 0.12). DISCUSSION: MUA is a safe and effective method to increase knee ROM in the setting of posttraumatic arthrofibrosis. Improvement in ROM was noted in all patients. A 90-day window between fracture fixation and manipulation did not impact ROM at final follow-up and may prevent fracture displacement during the MUA. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fascitis eosinofílica. A propósito de un caso / Eosinophilic fasciitis. Apropos of a case

La fascitis eosinofílica es un síndrome esclerodermiforme poco frecuente y de etiología desconocida que afecta predominantemente a las extremidades. Se han barajado varias hipótesis sobre su etiología y en algunos casos se ha descrito antecedente traumático. Presentamos un caso de una paciente de 54 años que tras presentar traumatismo sobre las rodillas inicia un cuadro de mialgias, induración cutánea y retracción progresiva de diversas articulaciones iniciado en los miembros inferiores y posteriormente en los miembros superiores y en el tronco. Realizamos el seguimiento de la paciente, mostrando su manejo desde el punto de vista rehabilitador y evolución. La paciente mejoró tanto sus balances articulares como la marcha y el dolor. La fascitis eosinofílica es una enfermedad infrecuente en la que debemos realizar el diagnóstico diferencial con otros síndromes esclerodermiformes. La rehabilitación puede ayudar a reducir y evitar el progreso de las contracturas (AU)

Eosinophilic fasciitis is a rare scleroderma syndrome of unknown cause that predominantly affects the extremities. Several hypotheses have been proposed to explain its etiology and there have been reports of some patients with a history of trauma. We present the case of a 54-year-old woman who, after a knee injury, developed myalgia, progressive skin induration and retraction of various joints, starting in the lower limbs and spreading to the upper limbs and trunk. We describe the rehabilitation management and outcome of this patient. The patient showed improvement in both balance, joint pain, and gait. Eosinophilic fasciitis is a rare disease that requires a differential diagnosis with other scleroderma syndromes. Rehabilitation can help reduce and prevent progression of contractures (AU)

Inter-clinician and intra-clinician reliability of force application during joint mobilization: a systematic review.

Joint mobilizations are commonly used by clinicians to decrease pain and restore joint arthrokinematics following musculoskeletal injury. The force applied during a joint mobilization treatment is subjective to the individual clinician but may have an effect on patient outcomes. The purpose of this systematic review was to critically appraise and synthesize the studies which examined the reliability of clinicians' force application during joint mobilization. A systematic search of PubMed and EBSCO Host databases from inception to March 1, 2013 was conducted to identify studies assessing the reliability of force application during joint mobilizations. Two reviewers utilized the Quality Appraisal of Reliability Studies (QAREL) assessment tool to determine the quality of included studies. The relative reliability of the included studies was examined through intraclass correlation coefficients (ICC) to synthesize study findings. All results were collated qualitatively with a level of evidence approach. A total of seven studies met the eligibility and were included. Five studies were included that assessed inter-clinician reliability, and six studies were included that assessed intra-clinician reliability. The overall level of evidence for inter-clinician reliability was strong for poor-to-moderate reliability (ICC = -0.04 to 0.70). The overall level of evidence for intra-clinician reliability was strong for good reliability (ICC = 0.75-0.99). This systematic review indicates there is variability in force application between clinicians but individual clinicians apply forces consistently. The results of this systematic review suggest innovative instructional methods are needed to improve consistency and validate the forces applied during of joint mobilization treatments. This is particularly evident for improving the consistency of force application across clinicians.

[Manual medicine and orthopedics]. / Manuelle Medizin und Orthopädie.

Manual medicine (MM) is a manual medical technique to identify and treat reversible dysfunction especially of the musculoskeletal system. The origins of MM were derived from empirical observations but MM is nowadays based on anatomy, biomechanics and neurophysiology. Besides special training in palpation according to precise topographic anatomic knowledge, the diagnostics of segmental or articular dysfunction are also based on knowledge about afferent convergence of multiceptive neurons located in proprioceptive and nociceptive layers of the brain stem and spinal cord. This leads to activation of motor and sympathetic reactions with the consequence of segmental or regional dysfunction. Manual therapy aims to eliminate noci-afferents as well as to activate inhibitory receptive fields. This can be achieved either by a single high velocity manipulative impulse or by slow-soft rhythmic repetitive mobilization. The special medical education and training in MM is outlined in relation to the Bologna postgraduate concept. As MM is basically used in relation to the musculoskeletal system it should definitely be incorporated into the specialization for orthopedics and traumatology and become part of the examination. In outpatient medicine an orthopedic and trauma surgeon without MM expertise will be inferior to a general practitioner with this expertise.

Polyethylene wear and osteolysis after cementless total hip arthroplasty with alumina-on-highly cross-linked polyethylene bearings in patients younger than thirty years of age.

BACKGROUND: We asked whether cementless total hip arthroplasties that made use of alumina-on-highly cross-linked polyethylene bearings would improve hip score and functional activity and reduce the prevalence of polyethylene wear, osteolysis, and aseptic loosening. METHODS: Consecutive primary total hip arthroplasties were performed in fifty patients (a total of sixty hips among thirty-four men and sixteen women) who were younger than thirty years of age. The average age at the time of the index arthroplasty was 28.3 years (range, twenty-one to twenty-nine years). The average follow-up was 10.8 years (range, ten to twelve years). Osteolysis and polyethylene wear rates were evaluated with use of radiography and computed tomography. RESULTS: The mean Harris hip score, which was 38 points (range, 6 to 45 points) preoperatively, had improved to 95 points (range, 85 to 100 points) at a mean follow-up time of 10.8 years. The mean penetration (and standard error of the mean) of the polyethylene liner was 0.031 ± 0.004 mm per year. No hip had osteolysis or aseptic loosening. CONCLUSIONS: At a minimum of ten years and an average of 10.8 years postoperatively, the current generation of cementless acetabular and femoral components with alumina-on-highly cross-linked polyethylene bearings was functioning well and was not associated with the development of osteolysis in our group of patients younger than thirty years of age. While the long-term prevalence of polyethylene wear and osteolysis remains unknown, the midterm data are promising.

Training the hip: a progressive approach.

In this article a progressive series of exercises to enhance motor control or movement competency of the hip are described. The training begins with control of center of mass during forward leaning by the muscles of the sole of the foot. This progresses to a novel lunge exercise emphasizing eccentric quadriceps control the knee. Then gluteal training is shown in a modern variation on Tai Chi along with a hip stability exercise during trunk rolling movements.

[Acupuncture in orthopedics]. / Akupunktur in der Orthopädie.

Large randomized controlled trials have shown the effectiveness of acupuncture in comparison to various control treatments for low back pain, osteoarthrosis, shoulder pain, tension type headache, and migraine. For most of these diseases the cost-effectiveness of acupuncture has been proven. A few smaller controlled trials exist for tennis elbow and osteoarthrosis of the hip. The use of acupuncture for other locomotive disorders is based on textbook literature and expert opinion. Current data show that acupuncture is a relatively safe method. Internationally several guidelines for chronic low back pain have integrated acupuncture. In Germany acupuncture has been reimbursed by the state insurance system for chronic low back pain and osteoarthritis since 2007 and the estimated costs are between EUR 300-700 million annually. Acupuncture is offered by at least 12,000 medical doctors and acupuncture is mostly used for locomotive disorders.

[Electroacupuncture in combination with rehabilitation for treatment of motor impairment after elbow operation].

OBJECTIVE: To compare the clinical effect on motor impairment after elbow operation between electroacupuncture combined with rehabilitation and rehabilitation training. METHODS: Fifty-three cases were randomized into an electroacupuncture combined with rehabilitation group (group A, 30 cases) and a rehabilitation group (group B, 23 cases). In group A, electroacupuncture was applied on the stiff region of the elbow and Sanjian (LI 3), Shousanli (LI 10), Hegu (LI 4), Yanglingquan (GB 34), Yinlingquan (SP 9) as adjunctive acupoints. Additionally, the passive movement was followed in the elbow joint after needles removed. In group B, the constant passive movement exercise was applied. The therapeutic effect was observed after 1.5 months of treatment. Mayo Elbow Performance Score (Mayo) and range of motion (ROM) were analyzed statistically after treatment in two groups. RESULTS: Mayo score and elbow ROM were all improved significantly after treatment in two groups (all P < 0.01). Compared with group B after treatment, the total Mayo score, joint motion range and ability as well as elbow ROM were all improved much apparently in group A (all P < 0.01). CONCLUSION: Compared with rehabilitation therapy, electroacupuncture in combination of rehabilitation training can achieve much significant effect on the motion function recovery of elbow joint after fracture operation.

Effects of electrical stimulation on muscle trophism in patients with hemophilic arthropathy.

OBJECTIVE: To determine changes occurring in the cross-sectional area, electromyography (EMG) activity, and the strength of the biceps brachii after an 8-week period of bilateral training with surface muscle electrical stimulation in patients with hemophilic arthropathy. DESIGN: Controlled trial. SETTING: Coagulopathy unit, university hospital. PARTICIPANTS: Volunteer subjects (N=30) participated in this study: 15 with severe hemophilia A (hemophilic group) and 15 nonhemophilic control subjects (control group). INTERVENTIONS: The hemophilic group followed a surface electrical stimulation program (frequency 45 Hz, impulse 200 micros, 10s on/10s off) over an 8-week period on the biceps brachii of both arms. The control group did no training of any kind. MAIN OUTCOME MEASURES: The cross-sectional area, maximum voluntary isometric contraction, and EMG activity of the biceps brachii in both arms were determined before and after the 8-week-long task. RESULTS: The results of the hemophilic group showed significant increases in the diameter (15.8%, P<.001), isometric force (4.6%, P<.05), and EMG activity (37.6%, P<.05) of the biceps brachii muscles in both arms. No significant changes were observed for the control group. CONCLUSIONS: Our findings confirm the efficacy of muscle electrical stimulation in causing muscles to hypertrophy in patients with hemophilia, thereby improving their muscular strength. In addition, these results may also be clinically applicable in the rehabilitation of patients who have similar deficiencies in the locomotor system.

Neck dissection and the clinical appearance of post-operative shoulder disability: the post-operative role of physiotherapy.

This paper critically reviews the literature, describing a post-operative phenomenon which is traditionally seen by physiotherapists in the immediate inpatient setting, following neck dissection (ND) for head and neck cancer. The presence and incidence of this condition is explored and the potential impact on the surviving patient's quality of life is considered. The nature and development of shoulder disability following ND is investigated and proposed roles of key anatomical structures involved are considered with relation to pathodynamics. A model for understanding the assessment and holistic management of this condition is offered and the potential implications for physiotherapy practice in primary care are considered.

Effectiveness of electroacupuncture and interferential eloctrotherapy in the management of frozen shoulder.

OBJECTIVE: To examine whether the addition of either electroacupuncture or interferential electrotherapy to shoulder exercises would be more effective in the management of frozen shoulder. DESIGN: A double-blinded, randomized, controlled trial. METHODS: A total of 70 subjects were randomly allocated to receive either: (i) electroacupuncture plus exercise; (ii) interferential electrotherapy plus exercise; or (iii) no treatment (the control group). Subjects in groups (i) and (ii) received 10 sessions of the respective treatment, while the control group received no treatment for 4 weeks. Each subject's score on the Constant Murley Assessment and visual analogue scale were recorded at baseline, post-treatment session and subsequent follow-up sessions. RESULTS: In both the electroacupuncture and interferential electrotherapy groups, the Constant Murley Assessment score increased and the visual analogue scale score decreased significantly (both p < 0.001). No significant change was found in any outcome of the control group, and no significant difference was found between the 2 intervention groups (all p > 0.05). The observed improvement was well maintained in both intervention groups at least until the 6-month follow-up session. CONCLUSION: Either electroacupuncture or interferential electrotherapy in combination with shoulder exercises is effective in treating frozen shoulder patients. However, no significant difference was found between these types of treatment.

[Functional disorders and functional diseases in the region of the upper cervical spine particularly regarding the cervical joints. Current status and clinical relevance]. / Funktionelle Störungen und funktionelle Erkrankungen im Bereich der oberen Halswirbelsäule unter besonderer Berücksichtigung der Kopfgelenke. Aktueller Stand und klinische Relevanz.

Functional disorders of the upper cervical spine may be responsible for or the primary cause of persistent complaints following an injury or illness. Functional disorders involving the cervical joints, especially C0/C1 and C1/2 but also the C2/3 junction are of particular clinical relevance. Range of motion assessment is extremely important for the diagnosis of joint disorders. Hypomobility or "blockade" can be diagnosed using special examination techniques that, in many cases, can be extended for direct manual therapy. Periarticular structures involved in these dysfunctional processes, especially muscles and fasciae, must also be examined and treated. Clinical manifestations may include locally restricted muscle extensibility (e.g., trigger points, tension or muscle shortening) with zones of radiating pain as well as referred problems distal to the primary lesion. Functional disorders in the region of the upper cervical spine may be accompanied by various types of reflexive compensatory problems. Although they must be diagnosed separately, these disorders frequently respond to the manual therapy techniques used to treat the underlying functional problem. Even if the exact correlations to functional medicine cannot be scientifically demonstrated in every case, functional assessment and treatment techniques are, in our view, a useful addition to the armamentarium for orthopedic diagnosis and treatment.

Equine rehabilitation therapy for joint disease.

The principles of physical rehabilitation therapy can be applied to the horse to provide a reduction in discomfort and dysfunction associated with the various forms of joint disease. Physical agents,such as ice, heat, electricity, sound, light, magnetic fields, compression, and movement, can be used by the rehabilitation therapist to attempt to control pain, reduce swelling, and restore optimal movement and function in the affected joint. The equine therapist's attention is focused not only on the affected joint but on the body as a whole to manage secondary or compensatory problems.

[Conservative treatment and rehabilitation of shoulder problems]. / Konservative Therapie und Rehabilitation von Schulterbeschwerden.

The shoulder joint has an important influence on arm- and hand function. Therefore, activities of daily living, working and leisure time can be negatively influenced by diseases of the shoulder joint. Problems of the shoulder joint can be induced by muscular dysbalance and poor body posture. There is a strong relationship between shoulder function and body posture. Conservative treatment and rehabilitation of the shoulder joint aims at improving the local dysfunction of the shoulder joint as well as at improving function and social participation. Antiinflammatory and pain medication, exercise, occupational, electro-, ultrasound and shock wave therapy, massage, thermotherapy and pulsed electromagnetic fields are used as conservative treatments. Exercise therapy aims at improving muscular performance, joint mobility and body posture. Occupational therapy aims at improving functional movements for daily living and work. Electrotherapy is primarily used to relieve pain. Shock wave and ultrasound therapy proved to be an effective treatment for patients with calcific tendinitis. The subacromial impingement syndrome can be effectively treated by conservative therapy.

[A novel device for active shoulder rehabilitation with glenohumeral traction or compression]. / Ein neuartiges Gerät zur aktiven Schulterrehabilitation unter glenohumeraler Traktion oder Kompression.

The equipment available for rehabilitation of patients with joint conditions still lacks a device that, in common with usual physiotherapeutic measures (manipulation, proprioceptive neuromuscular facilitation, Bobath therapy), is based on traction and/or compression or oscillating forms. The novel "Shoulder Rotator" is such a simple device for the variable treatment of shoulder disorders in all three spatial dimensions. After individual instruction, the patient performs rotating glenohumeral exercises with simultaneous glenohumeral joint traction, compression, or oscillations against static or dynamic resistance. The "Shoulder Rotator" is similar to the established continuous passive motion device for the shoulder and is mounted on a mobile chair. The electronic device control is computerised and permits a wide variety of treatment options, individual regimes, and documentation. The oscillating, compression/distraction mode of operation provides an analgesic effect. The isolated compression mode along the rotatory axis enables conditioning of joint proprioception. The distraction mode along the rotatory axis facilitates muscular relaxation. Resistive rotatory exercises strengthen the rotatory glenohumeral muscles and help centre the humeral head in the glenoid. In addition to the advantage of adding documentation of treatment progress as required for evidence-based medicine, this novel device may bring about a cost-effective, genuine quality improvement in shoulder rehabilitation.

Intensive rehabilitation of a knee joint in hemophilic patients--a preliminary study.

UNLABELLED: One of the most typical symptoms of hemophilia are the intra-articular hemorrhages, which cause chronic synovitis, damage of the joint and eventually hemophilic arthropathy. Adequate treatment of chronic synovitis with antihemophilic globulin combined with appropriate physiotherapy and rehabilitation is of primary importance for suspending development of hemophilic arthropathy. AIM: The present study aims to explore the changes in the range of movements in the knee joint, mass and strength of thigh musculature as well as gait stability in hemophilic patients after conduction of intensive rehabilitation programme. MATERIAL AND METHODS: Knee joints of 30 hemophilic patients were examined before and after conducting intensive rehabilitation. The assessments were done by angulometry of the knee joint, measurement of thigh circumference, and dynamometry. The rehabilitation course lasted 15 days. Kinesitherapy and modified physical factors were used in the treatment programme. Kinesitherapy included analytical exercises for the affected muscles and underwater gymnastics. The modified physical factors included electrotherapy with low-frequency impulse-magnetic field and interference currents. RESULTS: The applied intensive rehabilitation programme lead to variously expressed improvement of the examined parameters. CONCLUSION: The study results show that in most patients improvement of various degree is achieved which depends on the severity of damage of the locomotory apparatus. Prophylaxis with antihemophilic globulin combined with individually designed early rehabilitation is of crucial importance for maintenance of the musculoskeletal function in hemophilic patients.