Table 2.

The components of physical therapy in haemophilia management [22]

	Purpose	Techniques	Benefits
Flexibility/stretching	• Improve performance	• Static (passive) stretching	• Sustained (up to 24 h) elongation of soft tissues and muscles
	• Warm up before activity to reduce or prevent injury	• Ballistic (dynamic) stretching	• Reduced tension in skeletal muscles
	• Decrease muscle soreness	• PNF techniques	• Increased ROM (particularly with static stretching and PNF techniques)
	• Improve ROM
Strength	• Increase muscular strength, endurance, and power	• Isometric or isotonic strength training	• Increased joint and core muscle strength helps control exaggerated end-ROM joint movements and may therefore help prevent or decrease synovial impingement and associated haemarthroses or synovitis
	• Improve motor performance	• To strike a balance between improving strength and avoiding joint injury, it is important to learn proper techniques and train at submaximal loads, at a lower velocity and in limited joint ranges (even isometrically at various joint angles)
	• Increase cardiovascular fitness
	• Increase lean body mass and tissue tensile strength
	• Reduce pain
	• Reduce psychological stress
Sensorimotor retraining	• Promote joint stability and function using four main stages of rehabilitation:	• Electromyographic feedback	Electromyographic feedback:
	•Provide an optimal healing environment	• Hydrotherapy	• Trains the patient to produce greater amounts of force with static or dynamic exercise to elicit the same amount of sensory feedback
	•Restore muscle balance	• Various orthoses and footwear adaptations	Hydrotherapy:
	•Enhance motor function at the level of the brainstem		•Minimizes impact forces
	•Restore and increase endurance and coordinated muscle patterns		•Minimizes pain
			• Prevents rapid movement into ROM extremes where bleed risk is significant
			Orthoses and footwear adaptation:
			• Functional foot orthoses reduce pain and disability
Balance	• Treat balance impairments in haemophilia patients	• Start with simple exercises, such as lying on a hard floor, sitting on a rigid chair, kneeling, and standing	• Helps patients to perform daily activities and lead independent lives
	• Balance impairments may result from one or more of the following:	• More progressive exercises include shifting weight from one leg to the other, trunk rotations, arm/leg movements, and blindfolding
	•Degenerative joint disease (and repeated bleeds into joints and muscles)	• In later phases of rehabilitation, movable surfaces (e.g. steppers, rehabilitation balls, and balance boards) are added
	•Age-related decline in vision, proprioception, and vestibular function	• Patients with significant balance impairments are encouraged to use assistive devices (e.g. crutches, walkers, or canes)
	•Some medications (e.g. antidepressants)
Overall function	• Achieve the functional level the patient had before the last bleed	• Methods are similar to those used to learn a new sport, i.e. the patient practices the skill he wants to become proficient in performing	• Helps patients regain functional independence and maintain daily functioning
		•For example, using the sport-specific activity of throwing darts acts as a functional exercise in rehabilitating an elbow joint
		• Alternatively, occupational tasks can be used to achieve the same result
		•For example, a patient with adaptive muscle shortening in the upper extremity could use reaching tasks at work to maintain function and therapeutically address the established pathology

PNF, proprioceptive neuromuscular facilitation; ROM, range of motion.