"Hemophilia Vertical": Effects of Therapeutic Rock Climbing on Joint Health in Hemophilia Patients with Severe Arthropathies
Authors: Schroeder Courtney , Kallenbach Felix , Volland Lena , Barnes Richard FW , Moran Colleen M , Geyer Christine , von Velsen Regina , von Drygalski Annette , Stemberger Michaela Andrea 
Published: October 2019

Abstract
Background: Hemophilia is a bleeding disorder associated with frequent hemarthroses and ensuing debilitating arthropathies. Patients with hemophilia (PWH) are encouraged to participate in low impact physical activities to improve joint health, mobility, and quality of life (QoL). However, activities such as walking, swimming or physical therapy are often perceived as "boring", which results in participation in high risk activities that may cause injury or bleeding. Indoor therapeutic rock climbing is practiced successfully to improve physical and psychological well-being in patients with neuromuscular disorders, and may be a "fun" alternative for PWH. The aim of this study was to investigate the safety of therapeutic rock climbing and its effects on joint health for PWH with arthropathies.
Methods: Twelve adult male patients (median age 31 years, IQR=24,41) with moderate to severe hemophilia A and arthropathies (defined by decreased normative range of motion (ROM)) were recruited from the Hemophilia Treatment Centers at University of California, San Diego, USA (UCSD) and Ludwig Maximilians University, Munich, Germany (LMU)). All participants completed 12 sessions of individually tailored indoor top rope rock climbing, instructed by a climbing coach and physical therapist. Functional and clinical joint status including ROM, Hemophilia Joint Health Score (HJHS) for elbows, knees, and ankles (n=12), climbing skills (UCSD: Yosemite Decimal Scale; LMU: Union Internationale des Associations d'Alpinisme scale), QoL measures (UCSD: Haem-A-Qol, Hep-Test-Q; LMU: Hemo-Qol-A), annual bleed rate (ABR), and clotting factor consumption were assessed in both cohorts (UCSD n=6; LMU n=6) pre and post climbing. Additionally, effects on cartilage health, joint inflammation and soft tissue hypertrophy were assessed by musculoskeletal ultrasound and power doppler (MSKUS/PD) in the UCSD cohort. Descriptive statistics and Wilcoxon matched-pairs signed-rank tests were used for data analysis. Data are expressed as median and inter-quartile range; p-values ≤ 0.05 were considered significant.
Results: Compared to baseline, HJHS improved significantly after completion of the program (16.5 [IQR=6.0, 28.5] post vs 17.5 [6.0, 35.0] pre; n=12; p = 0.03). A significant increase in dorsiflexion was evident in arthropathic ankles (0 degrees [IQR= -4, 4] post vs -4 [IQR-10, -3] pre; n = 9; p<0.01), with trends towards increased ROM in arthropathic elbows and knees. All subjects advanced their climbing skills significantly (UCSD: 4 levels; LMU: 3 levels; both p-values =0.03). ABRs and clotting factor consumption were comparable before and during the climbing program for the UCSD cohort, whereas ABRs improved slightly in the LMU cohort in conjunction with pharmacokinetic tailored clotting factor therapy. Pre and post ABRs were 1 [IQR=0,4] and 0 [IQR=0,4] for the UCSD cohort (p = 1.00), and 5.5[IQR=1,8] and 1.7[IQR=0,2.3] for the LMU cohort (p=0.09), respectively. Clotting factor usage during climbing was similar between the 2 cohorts (UCSD 499 [IQR=298,593] U/kg/month; LMU 355 [IQR=250,490] U/kg/month, p = 0.39). Climbing resulted in significantly improved QoL in the LMU cohort (25.9 [IQR=21.4,30.0] points post vs 25.2 [IQR=21.0, 28.6] pre; n=6; p=0.05), but remained unchanged for the UCSD participants (p=0.31), possibly because of high QoL at outset. However, all UCSD participants voiced a meaningful increase of well-being and new confidence to overcome challenges. MSKUS/PD examinations of arthropathic joints revealed no negative effects on cartilage or soft tissue health, and demonstrated decreased inflammation.
Conclusions:Therapeutic rock climbing is not only safe but improves joint health and well-being in PWH with advanced arthropathies without triggering excessive clotting factor consumption. "Hemophilia Vertical" is an innovative athletic concept without the "boring" stigma of other low impact sports, and should be promoted to advance athletic hemophilia care concepts.

Disclosures
von Drygalski: Pfizer: Consultancy, Honoraria, Speakers Bureau; Biogen: Consultancy, Honoraria, Speakers Bureau; CSL-Behring: Consultancy, Honoraria, Speakers Bureau; Novo Nordisk: Consultancy, Honoraria, Speakers Bureau; Bayer: Consultancy, Honoraria, Speakers Bureau; Baxalta/Shire: Consultancy, Honoraria, Speakers Bureau; Hematherix LLC: Membership on an entity's Board of Directors or advisory committees.