Physiotherapy plays a vital role in managing acute bleeds in patients with hemophilia by following the PRICE principles: protection of the injured area, replacement of clotting factor, immobilization with splinting, application of ice, compression with bandaging, and elevation. The goals of physiotherapy are to treat muscle imbalances, reduce pain and improve function through stretching, strengthening, and correcting movement patterns to prevent further joint damage. The rehabilitation process begins with static exercises and progresses to range of motion, strength, proprioception, and weight bearing exercises as pain subsides and swelling decreases. Physiotherapy aims to educate patients, advise on joint protection and pain management, regularly assess joint status, and work as

1. PHYSIOTHERAPY MANAGEMENT
IN ACUTE BLEED
Presented by:
Dr. Hardik D. Patel
(B.P.T., P.G.D.H.H.M.)
(Hemophilia Society Rajkot Chapter)

2. Difficulties of Hemophilic Patient

4. Acute Bleeding means blood escaping from
the circulatory system.
Internally: Where blood oozing from
damaged blood vessels or organ inside the
body.
Externally: Where blood oozing due to
injury or trauma.

5. What is acute joint bleed?
People with hemophilia can bleed into
the joint space after an injury or at times
without obvious cause.
The pressure of blood filling the joint
cavity causes significant pain and can
lead to chronic swelling and deformity.

6. Joints
Affected by
Acute
Bleeding
Shoulder
Elbow
Wrist
Knee
Hip
Ankle

7. The Knees, Ankles and Elbows are more
commonly affected by acute bleeding than other
joints due to two reasons:
 These joints have one degree of freedom of
movement -as simple HINGE JOINTS, they can
only flex and extend.
 The hinge joints are not surrounded by other
protective muscles.

8. What are the symptoms of a joint bleed?
 Warmth
 Palpable swelling
 Tingling inside the joint
 Discomfort
 Pain
 Loss of motion
 Stiffness

9. What is Acute Muscle bleed ?
The bleeding can start after the
muscle is direct blow, sprained or
sudden stretch in the muscle.
With severe hemophilia, it can also
happen for no clear reason
(spontaneous bleed). Muscle
bleeds can cause a lot of blood loss
inside your body.

10. Forearm flexors
Biceps Brachii
Iliopsoas
(hip flexor)
Quadriceps Hamstrings
Calf
Muscles
Affected By
Acute Bleeding

11. What are the symptoms of a muscle
bleed?
 Aching in the muscle
 Trouble - moving arm or leg
 The muscle feels warmer than other
areas of skin
 Pain in the muscle
 Muscle feels tight or swells up
 Stiffness
 The skin over the muscle changes color
or becomes blue.

12.  Acute bleed should be treated as
quickly as possible, preferably within 2
hours.
 During acute bleed first appropriate
Factor should be administered.
Patient usually recognizes early
symptoms / “aura” of bleeding.

13. The treatment of disease, injury or
deformity by physical methods such as
Electric Modalities and some type of
proper Exercise rather than by drugs or
surgery...
What is Physical Therapy ?

14. Role of Physiotherapy
Physiotherapy plays a vital role in the
prevention/ minimizing of deformities and
disabilities associated with hemophilia
and facilitates a normal functional lifestyle.

15. Goals of Physiotherapy
Treatment of muscle imbalances
Ensure ↓ of pain and ↑ of function
Stretching to improve flexibility and prevent
muscle shortening
Prevent and correct muscle imbalances
Strengthening of muscles to improve stability
Posture training
Correction of wrong/ harmful movement
patterns and joint biomechanics to prevent
damage

16. Acute bleed
Principle of PRIICE
 P - Protection of the affected muscle or joint
 R - Replace the missing clotting factor
 I - Immobilize using a splint in the neutral
position
 I - Ice application
 C - Compression with a bandage
 E - Elevation of the area which is bleeding

17. Protect: Why?
To reduce pain
Minimize risk of causing another bleed
The joint is at its highest risk of re-injury in
the first 2 weeks
The muscle is at its highest risk of re-injury
in the first 6 weeks
Replacement:
Factor (If available)

18. Immobilize: How?
 NWB (Non weight bearing) of the affected limb
 Use crutches and splints
 Thermal plaster, back-slab (should be light) or
static splint
 Splint use in a comfortable position and
comfortable ROM (range of motion)
 No sports
 Move only within pain-free range
 Bed rest in cases of iliopsoas bleeds

19. Ice: Treatment protocol
 Ice apply on the affected area
 5 mins on, 10 mins off
 Place the ice circumferentially around the area
 Do not place the ice directly on the skin.
Use a towel or cloth as a barrier between skin
and ice
 Use ice before and after exercise

20. Compression:
 Slows bleeding
 Reduces swelling
 Reduces pain
 Limits movement of the joint
 Use crepe bandages
 Not too tight because it may cause more damage

21. When bleeding has stopped…
 After controlling acute bleeds
 Joints /muscles need to return to pre-bleed state
 Pre-bleed state depends on severity of bleeding
and length of rest/ immobilization
 Target joints are less likely to return to pre-bleed
state
Rehabilitation

22. During acute stage
 Start with gentle static muscle contraction (static
exercises) when pain allows
 This can commence while the area is still
bleeding
 5-10 contractions twice a day
 Progress to 15 contractions at least 3 times per
day when pain decreases and swelling is down

23. ROM
 Active stretching exercise
 Hold-relax stretching after immobilization phase
 Progress to contract-relax stretching
 Hold the stretch for 10 -15 seconds
 Serial splint can be used for prolonged stretching

24. Stretches
 Be careful, because over stretching can lead to
muscle bleed
 Active stretch is the best
 Passive gentle stretch until full stretch
 Serial splint for prolonged stretching (in case of
joint contracture)

25. Strength
 Muscles are weaker after immobilization and rest
 Isometric muscle contraction from acute stage
 Progress slowly to free active exercises:
- Inner range exercises
- Movement with gravity eliminated
- Movement against gravity

26. Proprioception
 Is a sense of posture, movement and change in
equilibrium and knowledge of position, weight
and resistance
 Very important to restore because it is good for
dynamic balance
 One-leg-stand test with eyes open and closed
 Walking on uneven surface, hopping, skipping
and stairs climbing

27. Weight bearing status
 NWB (non weight bearing) during acute stage with
crutches, splint
Progress to...
 PWB (partial weight bearing)
 FWB (full Weight Bearing)

28. Once the person resumes ADL
(activities of daily living),
this muscle usually regains its strength
without difficulty…
Swimming Is As Good as Soccer

29. Physiotherapy aims to:
• Educate people with hemophilia and their
families
• Advise patients about the importance of
joint protection
• Advise on treatment for pain and suffering
• Regularly assess and monitor joint status
• Work as part of the multidisciplinary team
to determine treatment modalities

30.  Physiotherapy is an important part of hemophilia
care
 The healing process will occur with good
rehabilitation techniques and is a slow process
 Working in a team with the Medico and
comprehensive care team is advantageous to the
PWH
 Proprioception needs to be worked on for every
bleed
 Exercises plays most important part in PWHs
life.
Summary

31. Your kind support will help us to achieve the
goal
“ Hemophilia with out disability,
Children free of pain.”
THANK YOU
Contributed by: Dr. Pamela Narayan