Early Physical therapy intervention following acute knee joint bleed in persons with Haemophilia in resource limited settings.

Patients with acute knee joint bleed will be assessed for eligibility and included in the study after a written consent. They will be evaluated by the Principal Investigator (PI) for acute joint bleed symptoms. When the patient is clinically diagnosed with acute bleed, they will be given clotting factor replacement therapy following which patient will be sent for Ultrasound for confirmation of diagnosis. Following ultrasound, patients will be taught POLICE protocol (Protection, Optimal Loading, Ice, Compression and Elevation) and asked to come for therapy the following day. They will be evaluated for movement and pain in the affected joint every day. If the patient is able to move the joint in the mid-range without pain and the pain on Visual Analogue Score (VAS) has reduced to less than 4/10, they will be included for graded Physiotherapy (PT). The number of days taken to start the graded PT will be taken as optimal rest period following knee joint bleed.

Before starting graded PT, a baseline assessment will be done by the physical therapist (Outcome assessor) who will be blinded to the group allocation. The assessment will include measurement of pain using VAS scale, swelling using inch tape, knee flexion and extension range using a universal goniometer and an accelerometer, muscle power using Modified Oxford scale for manual muscle testing, joint health using Haemophilia Joint Health Score (HJHS) and ambulatory status using functional mobility scale. Following this, the patients will be randomized using sequentially numbered, opaque, sealed envelope (SNOSE) to two groups. Physical therapy intervention for the two groups will be given by the PI. The interventional group will receive Hold-Relax technique along with 2 weeks of graded PT. The control group will receive only 2 weeks of graded PT. Graded PT will include isometric exercises, multiangled isometrics, static stretching, concentric and eccentric exercises, closed and open kinematic chain exercises and progressive gait training.

At the end of 2 weeks, the outcomes will be re-assessed by the physical therapist (blinded outcome assessor). The data will be analyzed to find out if addition of Hold-relax technique to a 2 – week graded physiotherapy program helped in improving the joint range of motion when compared to the control group. A follow-up assessment will be done at 3 months to re-assess the outcomes and to find out if there were any re-bleeds. In addition, the correlation between clinical and ultrasound diagnosis of acute knee joint bleed; the impact of cryotherapy on pain and duration of rest period; and optimal time for rest following acute knee joint bleed will also be analyzed.