Maintenance of musculoskeletal function in people with haemophilia L. R. BATTISTELLA Director, Rehabilitation Unit, University of SaÄo Paulo General Hospital, SaÄo Paulo, Brazil The prevention of musculoskeletal disorders in haemophilic patients is more outcome-effective and presents a better cost-to-bene®t ratio than the inad- equate treatment of bleeds [1±4]. Prevention pro- grammes can be separated into three levels: 1 secondary prevention; 2 tertiary prevention principally of chronic synovitis; 3 rehabilitation and functional adaptation to dis- ability. Total primary prevention for haemophilic musculo- skeletal disorders is probably impossible to achieve because of the rate of nonfamilial haemophilia cases secondary to genetic mutations [1, 4]. These patients have frequently had musculoskeletal bleeds before presentation for diagnosis. Secondary prevention Early diagnosis of musculoskeletal haemorrhage and prevention of the sequelae are the main objectives of a rehabilitation programme for haemophilic patients [2]. It is important to educate the patients and their families about the importance of an early diagnosis and proper treatment. Early diagnosis is the key element needed to curtail the pathology of musculo- skeletal sequelae. Secondary prevention during the developmental years poses a special challenge to health-care profes- sionals because of the limitations to some preventive approaches [4, 5]. Preventive recommendations for haemophilic children up to 2 years of age are: · avoid stretching the upper limbs when helping the child sit up; · let the child stand naturally at 9±12 months of age; · encourage sitting with no support for the upper body. This will strengthen the paravertebral mus- cles and promote a more ef®cient independence of movement between the shoulder and pelvic girdles; · stimulate bimanual skills during the ®rst few months to help the development of ®ne co- ordination mechanisms, muscle activation and enhance resistance to microtrauma; · avoid gait-helping devices during gait develop- ment; · watch for signs of muscle and joint problems after falls. Parents should be encouraged to teach their child that treatment is essential for recovery [3, 5]. Passive movement of joints is helpful. The child should be encouraged to lead a healthy and active life. How- ever, direction should be given to the family about limitations and risks. Onset of unassisted gait coincides with the time when the incidence of articular haemorrhage increas- es [3±5]. At this age, the input and processing of new sensory information helps the child's nervous system to organize complex motor skills such as gait and ®ne bimanual tasks. The development of the child's motor skills will bene®t from: · short phrases spoken in a soft voice, guiding the child though a motor task on a step-by-step basis; · anticipation of the movement to be executed, so that the motion is slow and well programmed; · planning each step to be taken on the way to reach a given object. Physical activity and sport always have an appeal for children, and they should become a family value. Safe recreational activities with parents should be encouraged, and adapted if joint problems emerge. However, a sense of competitiveness should not be stimulated in young children, when their frustration threshold is at its lowest. Physical activities recommended for older haemo- philic children are: · swimming; Correspondence: Linamara Rizzo Battistella, MD, PhD, Divisa Äo Reabilitac Ëa Äo do Hospital das Clõ Ânicas da Faculdade de Medicina da Universidade de Sa Äo Paulo, Rua Diderot 43, Sa Äo Paulo, Sa Äo Paulo CEP 04116±030, Brazil. Tel: (55±11) 5497501 2826120; fax: (55±11) 5490556; e-mail: clamefa@uninet.com.br Haemophilia (1998), 4, (Suppl. 2), 26±32 26 Ó 1998 World Health Organization