Introduction. Chronic pain is a frequent complication in adults with hemophilia and hemophilic arthropathy that affects functionality and quality of life. In addition to joint damage, central pain mechanisms and psychological factors may contribute to its functional impact, although evidence in this population is limited.
Objective. To analyze the association between central pain mechanisms, pain intensity, and pain-related anxiety and pain interference in daily life in adults with hemophilia and hemophilic arthropathy, adjusting for relevant clinical variables.
Methods. An analytical observational study with a cross-sectional design will be conducted in 138 adults with hemophilia and hemophilic arthropathy. The dependent variable will be pain interference in daily life (Brief Pain Inventory), the main predictor variables will be central sensitization (Central Sensitization Inventory), conditioned pain modulation (Conditioned Pain Modulation Index), global pain intensity (severity subscale of the Brief Pain Inventory), and pain-related anxiety (Pain Anxiety Symptoms Scale-20). As secondary predictor variables, sleep quality (Pittsburgh Sleep Quality Index) and pain self-efficacy (Pain Self-Efficacy Questionnaire) will be included. As confounding variables, joint damage, age, type of treatment, and history of inhibitor will be considered. The association between variables will be analyzed using multiple linear regression models adjusted for relevant clinical covariates.
Expected results. It is expected to identify factors associated with pain interference in adults with hemophilia and hemophilic arthropathy, improving the understanding of its functional impact.
Diagnosis of hemophilia A or B
Age equal to or greater than 35 years
Clinical diagnosis of hemophilic arthropathy in at least one lower limb joint
Clinically relevant joint involvement, defined as a total score on the Hemophilia Joint Health Score (HJHS) greater than 4 points
Presence of neurological or cognitive impairments that prevent understanding of the questionnaires or performance of the study tests
Episode of hemarthrosis in the lower limbs within the 3 months prior to assessment
Use of analgesics, nonsteroidal anti-inflammatory drugs, opioids, or other medications with potential effects on pain perception or modulation within the 72 hours prior to assessment
Receiving, at the time of the study, physiotherapy, infiltrative, or orthotic interventions aimed at pain or function of joints affected by hemophilic arthropathy
Patients with hemophilia
Cohort
Cross-sectional
Not listed
Assessment of pain interference in daily life and global pain intensity at baseline.
The Brief Pain Inventory (BPI-Interference) will be used to assess pain interference in daily life and global pain intensity. This instrument measures the extent to which pain interferes with basic and relevant activities such as general activity, walking, normal work, mood, sleep, social relations, and enjoyment of life. It does not assess pain mechanisms, but rather their perceived functional impact. It consists of 7 items scored from 0 to 10 (0: does not interfere; 10: completely interferes), and the total score is obtained by calculating the mean of the items.
Assessment of central sensitisation at baseline.
The Spanish version of the Central Sensitization Inventory will be used to assess the presence of central sensitisation in patients. This inventory includes a first part with 25 items that assess symptoms associated with central sensitisation. Each item is evaluated using a 5-point Likert scale with a numerical hierarchy: Never (0), Rarely (1), Sometimes (2), Often (3), and Always (4). The second part assesses whether the patient has any diagnosis among a list of 10 disorders, including the year of diagnosis. The score of the first part ranges from 0 to 100 points, where higher scores indicate greater clinical severity.
Assessment of conditioned pain modulation at baseline.
The Conditioned Pain Modulation Index (CPMI) will be used to assess endogenous pain inhibitory function. Pressure pain threshold (PPT) will be measured at the dorsal aspect of the distal phalanx of the thumb before and during a conditioned stimulus induced by an ischemic test in the contralateral upper limb (sphygmomanometer inflated to 240 mmHg). Patients will report pain intensity on a numerical rating scale (0-10) until reaching 7/10, supported by wrist extension exercises if needed. PPT will be reassessed during the conditioned stimulus. The cuff will remain inflated for up to 6 minutes.
Assessment of pain-related anxiety at baseline.
The Pain Anxiety Symptoms Scale-20 (PASS-20) will be used to assess levels of pain-related anxiety. This scale includes 20 items and measures anxiety and fear responses associated with the experience of chronic or recurrent pain. Each item is scored on a scale from 0 to 5, where 0 indicates "never" and 5 indicates "always". It evaluates different dimensions of pain-related anxiety, including cognitive, physiological, and behavioural responses associated with pain experience.
Assessment of sleep quality at baseline.
Sleep quality will be assessed using the Pittsburgh Sleep Quality Index. The original version consists of 19 items. The first four items have an open-ended response format and assess sleep duration. The remaining items are related to sleep disturbances and daytime dysfunction. Using a 4-point Likert scale, the frequency of each situation is indicated (0: not during the last month; 1: less than once per week; 2: once or twice per week; 3: three or more times per week) and overall sleep quality is rated (0: very good; 1: fairly good; 2: fairly bad; 3: very bad). Scores are distributed across different components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. Each component ranges from 0 to 3, with a global score ranging from 0 to 21. Higher scores indicate greater disturbance in the evaluated sleep components. A global score greater than
Assessment of the sociodemographic variable age at baseline
The sociodemographic variable age will be measured in months completed from the patient's date of birth to the date of the assessment.
Assessment of the clinical variable development of inhibitors at baseline
The clinical variable development of inhibitors to clotting factor concentrates will be measured using a dichotomous qualitative variable with two response options: yes/no.
Assessment of the clinical variable type of treatment at baseline
The clinical variable type of treatment will be measured using a dichotomous qualitative variable with two response options: on deman / prophylaxis
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