1. bookVolume 9 (2022): Edizione 1 (January 2022)
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2055-3390
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22 Dec 2017
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Point of care ultrasonography in patients with haemophilia and acute haemarthrosis: a physiotherapist and sonographer inter-professional agreement pilot study

Pubblicato online: 20 May 2022
Volume & Edizione: Volume 9 (2022) - Edizione 1 (January 2022)
Pagine: 64 - 75
Dettagli della rivista
License
Formato
Rivista
eISSN
2055-3390
Prima pubblicazione
22 Dec 2017
Frequenza di pubblicazione
1 volta all'anno
Lingue
Inglese
Abstract Background

Haemophilia treatment centres (HTCs) around the world are increasingly adopting point-of-care ultrasonography (POCUS) for the assessment of acute haemarthrosis and to monitor joint health. POCUS is in large part administered by physiotherapists in most comprehensive care teams. Appropriate implementation of haemophilia-specific POCUS requires an educational foundation and training to ensure competency and optimal outcomes. Inter-professional agreement and evaluation of image quality are important measures of competency and acceptable use of POCUS.

Aims

To determine the level of agreement between physiotherapist and sonographer-performed POCUS scans and to compare the quality of the ultrasound images obtained by physiotherapists to those obtained by the sonographer.

Methods

This single blind, prospective, pilot study recruited patients with haemophilia A and B who presented to clinic with a suspected acute haemarthrosis of the elbow, knee, or ankle and consented to participate. POCUS scans were performed by one trained physiotherapist and one sonographer in the haemophilia ambulatory clinic at patient presentation, one-week follow-up, and two-week follow-up. The physiotherapist participated in formal training consisting of 12 hours of online didactic modules and a two-day, 12-hour practical module with instructor-led hands-on training. For the primary objective, the outcome of interest was the binary decision on the presence or absence of blood within the joint. For the secondary objective, image quality was evaluated by the radiologist post hoc and rated as optimal, acceptable, or sub-optimal.

Results

Thirteen participants with haemophilia consented to the study. The results indicated an excellent level of agreement (k=0.80) with an observed agreement of 91.7%, a specific positive agreement of 94.1%, and a specific negative agreement of 85.7% for the detection of blood within the joint space. The quality of the ultrasound images obtained by the physiotherapist were rated by the radiologist as optimal (84.6%) and acceptable (15.4%). None of the images were rated as sub-optimal.

Conclusion

Optimal image quality and a high level of agreement between the physiotherapist and sonographer-performed POCUS for the assessment of acute hemarthrosis in people with haemophilia A and B was observed. These results suggest that, with a short formal training programme, physiotherapists can be proficient in the performance, acquisition, and interpretation of POCUS scans in patients with haemophilia.

Keywords

<figure id="j_jhp-2022-0008_fig_011" position="float" fig-type="figure"><figCaption><p>With appropriate training, physiotherapists can perform and interpret point-of-care ultrasound scans for the assessment of acute haemarthrosis to a level comparable to an experienced sonographer</p><p>© Shutterstock</p></figCaption><img xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_jhp-2022-0008_fig_011.jpg" src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_011.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=7aa18200981337166cb758b459caba9ef30949a8c8bd6022b6f0324cfa0da3d4" class="mw-100"></img></figure> <p>Haemophilia is a haematological condition with orthopaedic manifestations. People with haemophilia (PwH) are prone to several complications. Haemarthrosis is the most frequent complication, accounting for 70–80% of all bleeding episodes <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_001">1</a>]</sup>. Although any joint may be affected, hinge joints, particularly the ankles, knees and elbows, are the most commonly involved <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_001">1</a>]</sup>. Blood within the joint space has detrimental effects on all joint structures and leads to the development of haemophilic arthropathy <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_002">2</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_003">3</a>]</sup>. A single haemarthrosis is capable of causing the same long-term arthropathy as seen in recurrent haemorrhages <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_004">4</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_005">5</a>]</sup>. Time between the initiation of joint bleeding symptoms and treatment with factor replacement therapy is crucial; however, some haemarthroses may present ambiguously. On initial presentation it may be difficult to assess if acute joint pain is due to a joint bleed or underlying arthropathy <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_006">6</a>]</sup>. Recent evidence suggests that clinical examination alone is not sensitive enough to detect small amounts of blood within a joint <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_004">4</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_006">6</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_007">7</a>]</sup>. Therefore, each bleeding event requires early and complete bleed assessment and management to ensure the best possible outcomes for PwH.</p> <p>Magnetic resonance imaging (MRI) is the gold standard for the detection of haemarthrosis, however it is expensive, often inaccessible, and may require sedation of children to ensure that the images are not compromised by patient movement <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_008">8</a>]</sup>. Computed tomography (CT) is another sensitive method; however, the benefits of CT may not outweigh the downside of ionising radiation <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_008">8</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_009">9</a>]</sup>. Ultrasound is time-efficient, nonionising, and relatively inexpensive <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_008">8</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_010">10</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_011">11</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_012">12</a>]</sup>. Ultrasound can detect complex fluid suggestive of blood within the joints of patients who are clinically asymptomatic, leading to the recommendation that ultrasound be used in combination with the clinical exam to inform treatment decisions following haemarthrosis <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_007">7</a>]</sup>. However, clinical integration of ultrasound is limited by timely access to sonographers/radiologists with knowledge and experience in haemophilia. Further, treatment of haemarthrosis is time-sensitive, and same-day diagnostic imaging appointments are not always feasible. Point-of-care ultrasound (POCUS) is a modality that has the potential to address many of these challenges. POCUS is performed by a health care professional (HCP) at the bedside or in the ambulatory clinic, in combination with the clinical examination to identify the presence or absence of a specific clinical finding <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_013">13</a>]</sup>. POCUS should be utilised when time saving for diagnosis or treatment is critical to patient care <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_013">13</a>]</sup>. However, POCUS is a highly user-dependent modality, and there is a risk of misdiagnosis if it is used to aid clinical decision-making by inexperienced or untrained HCPs <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_014">14</a>]</sup>.</p> <p>Proficiency with the clinical examination and an understanding of the role of POCUS are important competencies for physiotherapists <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_015">15</a>]</sup>. POCUS has been described within physiotherapy practice in orthopaedics or sport injuries to detect atrophy, tendon, ligament or muscle injury, in rheumatology to assist clinical decisions, and as a potential tool for physiotherapists working in critical care <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_016">16</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_017">17</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_018">18</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_019">19</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_020">20</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_021">21</a>]</sup>. It is important that physiotherapists who are using POCUS have confidence in their interpretation and findings, as this could impact the credibility of the profession, patient safety, support from regulatory colleges and licensing bodies, and collaboration with medical colleagues. A survey of orthopaedic surgeons and radiologists in the Netherlands reported no additional value of physiotherapist-performed POCUS in primary care <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_022">22</a>]</sup>. This is a single study that assessed the subjective opinions of survey respondents; perceived disadvantages of physiotherapist-performed POCUS were false-positive or false-negative results, lack of experience, inadequate training, and the inability to correlate the reported findings on POCUS with other forms of imaging <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_022">22</a>]</sup>. Even though this study reported a low survey response rate and a potential for response bias, the lack of trust radiologists and orthopaedic surgeons reported for physiotherapist knowledge and performance of POCUS in primary care should be addressed through future studies <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_022">22</a>]</sup>. Rathi and colleagues investigated the inter-rater reliability of glenohumeral joint translation using POCUS <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_023">23</a>]</sup>. Although high intra-rater reliability (physiotherapist: ICC 0.86–0.98, expert sonographer: 0.85–0.96) was found, it was moderate to good for posterior measurements (ICC 0.50–0.75) and poor to moderate for anterior measurements (ICC 0.31–0.53). These results suggest that to improve inter-rater reliability with an expert sonographer, the physiotherapist may benefit from additional or a different form of training <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_023">23</a>]</sup>. Similar findings were reported by Thoomes-de Graaf and colleagues, who found a kappa coefficient of 0.36 between physiotherapists and radiologists on the use of diagnostic ultrasound in patients with shoulder pain across four diagnostic categories <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_024">24</a>]</sup>. Although the level of agreement was low, this study reported that physiotherapists with more experience and training had a higher level of agreement with the radiologist than novice physiotherapists <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_024">24</a>]</sup>.</p> <p>Training appears to be an important contributor to inter-rater reliability of physiotherapist-performed POCUS. Mayer and colleagues found excellent inter-rater reliability (ICC range 0.76–0.97) between a physiotherapist, physiotherapy students, and an expert physician sonographer following eight hours of structured formal training as a group and a one-hour private practical training session with the expert sonographer <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_025">25</a>]</sup>. An inter-examiner agreement study of physiotherapists in the Netherlands found an acceptable level of overall agreement (61.7–93.6%) and specific positive agreement (43.9–91.4%) for detecting rotator cuff tears and other pathology <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_026">26</a>]</sup>. The physiotherapists in this study had obtained certification on basic musculoskeletal ultrasound skills and completed a six-hour training programme specific to the study protocol with an expert in musculoskeletal sonography <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_026">26</a>]</sup>.</p> <p>Physiotherapists in haemophilia treatment centres (HTCs) have extensive knowledge of anatomy, pathophysiology, and functional implications of a bleeding disorder on the musculoskeletal system. A global survey of HTCs found that the majority (70%) of POCUS scans were completed by physiotherapists <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_027">27</a>]</sup>. In this study, an interdisciplinary panel of haematologists/oncologists, radiologists, and physiotherapists reported that physiotherapists are appropriate users for the acquisition and interpretation of POCUS scans in HTCs <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_027">27</a>]</sup>. While several researchers have studied diagnostic ultrasound and the correlation with disease activity and haemophilic arthropathy, inter-professional agreement and an evaluation of image quality for physiotherapist-performed POCUS in PwH with acute haemarthrosis has not been investigated <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_028">28</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_029">29</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_030">30</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_031">31</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_032">32</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_033">33</a>]</sup>. Inter-professional agreement and evaluation of image quality are important measures of competency and acceptable use of POCUS. Image quality provides evidence to support the diagnosis of a bleed and decreases the chance of artifact incorrectly demonstrating pathology. Given the role of physiotherapists within HTCs in Canada, and the emergence of POCUS, the present pilot study aims to add novel research to this discussion.</p> <p><bold>Objectives:</bold> <list list-type="order"> <list-item><p>To determine the level of agreement between physiotherapist and sonographer-performed POCUS to assess for the presence or absence of blood in acute haemarthrosis in people with haemophilia A and B.</p></list-item> <list-item><p>To compare the quality of the ultrasound images obtained by the physiotherapist to those obtained by the sonographer.</p></list-item></list> </p> </sec> <sec id="j_jhp-2022-0008_s_002"><div>METHODS</div> <sec id="j_jhp-2022-0008_s_002_s_001"><div>Study design</div> <p>This study was a single blind, prospective, pilot study.</p> </sec> <sec id="j_jhp-2022-0008_s_002_s_002"><div>Participants</div> <p>A convenience sample of PwH with a suspected acute hemarthrosis of the elbow, knee, or ankle were recruited from a single HTC in Canada. The physiotherapist (KS) who performed the POCUS scan is a member of the Canadian Physiotherapists in Hemophilia Care, successfully completed the McMaster University Mohawk College POCUS Training Program for Acute Hemarthrosis and Synovitis, and has 17 years of experience in haemophilia care. The training programme includes 12 hours of online didactic modules and a two-day, 12-hour practical training module with instructor-led hands-on practice <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_034">34</a>]</sup>. The didactic modules include summative assessments, and the practical component includes an assessment of competency using a simulated performance environment. The assessments were created to model the Sonography National Competency Profile developed by Sonography Canada and the Sonography Canada Clinical Skills Assessment Tool for this specific application of POCUS <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_034">34</a>]</sup>. The sonographer (LF) who performed the ultrasound scan is a senior sonographer in the diagnostic imaging department at a large tertiary care hospital and has over 30 years of clinical experience in sonography. A single radiologist (NS) with 12 years of experience in ultrasound imaging and 10 years’ experience in paediatric imaging, provided oversight to the study and reviewed all POCUS scans and case report forms.</p> </sec> <sec id="j_jhp-2022-0008_s_002_s_003"><div>Study procedures</div> <p>The study procedure consisted of a POCUS performed by a physiotherapist and a sonographer. The POCUS scanning procedure is presented in <a ref-type="app" href="#j_jhp-2022-0008_app_001">Appendix 1</a>. The POCUS scans were performed in the haemophilia ambulatory clinic at patient presentation, one-week follow up, and two-week follow-up. The order of assessment was based on clinician availability. The sonographer was allowed to add additional images to the imaging protocol given their area of expertise, but the physiotherapist was instructed to acquire the images according to the scanning procedure. Ambiguous results were referred to the diagnostic imaging department for further formal investigation. Both the physiotherapist and the sonographer were blinded to each other's findings and to the results of previous scans. Methods of blinding included the use of a private clinic room and each clinician performing their assessment and documentation independently. Case report forms were placed in a sealed envelope. POCUS images were saved on the hard drive of the POCUS machine (GE Logiq) using an anonymous participant identification number.</p> </sec> <sec id="j_jhp-2022-0008_s_002_s_004"><div>Inclusion and exclusion criteria</div> <p>Patients (age >1 year of age) with haemophilia A or B, with an acute haemarthrosis involving the elbow, knee, or ankle who presented to the clinic within five days of symptom onset were eligible to participate. Participants were excluded if there was an open wound over the scanning area, if an ultrasound scan of the haemarthrosis had already been completed, or if they were not able to read and understand English.</p> </sec> <sec id="j_jhp-2022-0008_s_002_s_005"><div>Outcome assessment</div> <p>Outcomes were assessed at presentation, one-week follow-up, and two-week follow up, resulting in a three-week study period. For the primary objective, the outcome of interest was the binary decision on the presence or absence of blood within the joint. As the technique and protocol in this study was specific to haemophilia, the criteria used to distinguish blood from effusion on ultrasound was blood presents as a complex fluid collection with mixed echogenicity and displaceable speckles on real time compression and effusion presents as simple anechoic fluid with the absence of echoes <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_035">35</a>]</sup>. In the context of haemophilia with no symptoms suggestive of infection, complex effusions with mixed echogenicity can be assumed to represent haemarthrosis based on previous studies that have documented the accuracy of this approach using joint aspiration <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_035">35</a>]</sup>. The physiotherapist completed the scanning protocol and interpreted the findings to make the binary assessment. Since interpreting ultrasound falls outside the scope of the sonographer, the sonographer provided an impression on the presence or absence of blood on the case report form. The radiologist read the sonographer images and provided a final diagnosis. The radiologist also reviewed the images of the physiotherapist performed ultrasound. To compare the level of agreement, the radiologist's final diagnosis was compared to the physiotherapist's interpretation. Both the physiotherapist and the sonographer recorded inconclusive ultrasound findings as absence of blood within the joint.</p> <p>For the secondary objective, criteria used to evaluate image quality were appropriate pre-sets, depth, field of view, focus, gains/time gain compensation, colour and/or power Doppler, with suitable landmarks and annotation. Image quality was evaluated by the radiologist post hoc and rated as optimal, acceptable, or sub-optimal. Optimal was defined as good image quality with optimal ultrasound settings and correct annotation/documentation. Acceptable was defined as good image quality, with one image setting that should have been better optimized or a minor error in annotation/documentation that did not impact the interpretation of the POCUS scan. Sub-optimal was defined as poor image quality with more than one image setting not sufficiently optimised or an error in annotation/documentation that impacted the radiologists’ interpretation of the POCUS scan.</p> </sec> <sec id="j_jhp-2022-0008_s_002_s_006"><div>Statistical analysis</div> <p>For the primary objective, the prevalence of positive findings was calculated. The inter-rater agreement of the binary assessment of the presence and absence of blood within the joint was assessed with the kappa coefficient and 95% confidence intervals for the total sample and interpreted according to the categories by Landis and Koch <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_036">36</a>]</sup>. As this is a pilot study, we did not set an a priori threshold for agreement. Observed agreement, specific positive agreement and specific negative agreement were also calculated to provide the results in a clinically relevant format <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_037">37</a>]</sup>. For the secondary objective, the quality of the images was independently rated by the radiologist. Descriptive statistics including counts and percentages of optimal, acceptable, and sub-optimal for the physiotherapist and the sonographer performed POCUS scans were reported.</p> </sec> <sec id="j_jhp-2022-0008_s_002_s_007"><div>Ethics approval</div> <p>The proposed study received research ethics board approval from the Hamilton Integrated Research Ethics Board. All participants provided informed consent to participate in the study.</p> </sec> </sec> <sec id="j_jhp-2022-0008_s_003"><div>RESULTS</div> <p>Thirteen PwH met the inclusion criteria and were recruited into the study. Two of the POCUS scans involved elbows (15.4%), five (38.5%) ankles, and six (46.2%) knees. The median age of participants was nine years (interquartile range: five years).</p> <sec id="j_jhp-2022-0008_s_003_s_001"><div>Level of agreement on the presence or absence of blood within the joint</div> <p>As presented in <a ref-type="table" href="#j_jhp-2022-0008_tab_001">Table 1</a>, the kappa coefficient was k=0.80 (95% CI, 0.59–1.00). The prevalence of positive findings was 70.8%, observed agreement was 91.7%, the specific positive agreement was 94.1%, and the specific negative agreement was 85.7%. The sonographer was absent and unable to complete three POCUS scans, these scans were excluded from the level of agreement analysis.</p> <table-wrap id="j_jhp-2022-0008_tab_001" position="float"><label>Table 1</label><caption><p>Level of agreement on the presence or absence of blood within the joint</p></caption> <table frame="hsides" rules="cols"> <thead> <tr> <th align="left" valign="top"/> <th align="left" valign="top"><bold>KAPPA COEFFICIENT</bold></th> <th align="left" valign="top"><bold>AGREEMENT</bold></th> </tr> <tr> <th align="left" valign="top" colspan="3"><hr/></th> </tr> </thead> <tbody> <tr> <td align="left" valign="top">Overall (n= 36)</td> <td align="left" valign="top">k=0.80 (95% CI, 0.59–1.00) p=0.000</td> <td align="left" valign="top">Prevalence: 70.8%<break/>OA: 91.7%<break/>SPA: 94.1%<break/>SNA: 85.7%</td> </tr> </tbody> </table> <table-wrap-foot> <fn-group> <fn><p>k: kappa coefficient; OA: observed agreement; SPA: specific positive agreement; SNA: specific negative agreement</p></fn> </fn-group> </table-wrap-foot> </table-wrap> </sec> <sec id="j_jhp-2022-0008_s_003_s_002"><div>Quality of ultrasound images</div> <p>Post hoc analysis of the quality of the ultrasound images is shown in <a ref-type="table" href="#j_jhp-2022-0008_tab_002">Table 2</a>. The physiotherapist-performed POCUS scans demonstrated that 84.6% of the images were rated by the radiologist as optimal, 15.4% were rated as acceptable, and none were rated as sub-optimal. For the sonographer-performed POCUS scans, 88.9% of the images were rated as optimal, 11.1% were rated as acceptable, and none of the scans were rated as sub-optimal.</p> <table-wrap id="j_jhp-2022-0008_tab_002" position="float"><label>Table 2</label><caption><p>Quality of ultrasound images</p></caption> <table frame="hsides" rules="all"> <thead> <tr> <th align="left" valign="bottom" rowspan="2"/> <th align="center" valign="bottom" colspan="3"><bold>QUALITY OF ULTRASOUND IMAGES</bold></th> </tr> <tr> <th align="left" valign="bottom"><bold>OPTIMAL</bold></th> <th align="left" valign="bottom"><bold>ACCEPTABLE</bold></th> <th align="left" valign="bottom"><bold>SUB-OPTIMAL</bold></th> </tr> </thead> <tbody> <tr> <td align="left" valign="top">Physiotherapist</td> <td align="left" valign="top">84.6%</td> <td align="left" valign="top">15.4%</td> <td align="left" valign="top">0%</td> </tr> <tr> <td align="left" valign="top">Sonographer</td> <td align="left" valign="top">88.9%</td> <td align="left" valign="top">11.1%</td> <td align="left" valign="top">0%</td> </tr> </tbody> </table> <table-wrap-foot> <fn-group> <fn><p>Optimal: good image quality with optimal ultrasound settings and correct annotation/documentation</p></fn> <fn><p>Acceptable: good image quality, one image setting should have been better optimised or a minor error in annotation/documentation that did not impact POCUS interpretation</p></fn> <fn><p>Sub-optimal: poor image quality with more than one image setting not sufficiently optimised or an error in annotation/documentation that impacted POCUS interpretation</p></fn> </fn-group> </table-wrap-foot> </table-wrap> </sec> </sec> <sec id="j_jhp-2022-0008_s_004"><div>DISCUSSION</div> <p>Although pilot in design, this study adds to the emerging literature supporting the quality of physiotherapist-performed POCUS. The level of agreement between physiotherapist and sonographer is encouraging, suggesting that a trained physiotherapist is able to acquire and interpret POCUS scans of acute haemarthrosis in patients with haemophilia A and B at the same level of expertise as an experienced sonographer <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_036">36</a>]</sup>. The specific positive agreement was greater than the specific negative agreement indicating better agreement when confirming the presence rather than the absence of blood within the joint. Clinically, these results indicate that if the physiotherapist performed and interpreted the POCUS scan as positive for presence of blood within the joint, the probability that the sonographer and radiologist would also confirm haemarthrosis is 94.1%. Encouraging results were also found for the absence of blood within the joint with the probability of absence of blood at 85.7%. While agreement was less for the absence of blood, the results were still high. Clinically, this supports physiotherapist consultation with radiology to determine whether further imaging is required if the POCUS scan indicates a lack of blood in the joint but other indicators such as patient symptomatology, mechanism of injury, inhibitor status, trough level, and underlying joint health, are all highly suggestive of haemarthrosis. The quality of the images obtained by the physiotherapist were optimal and comparable to the sonographer. This indicates that the trained physiotherapist was able to produce images that support the diagnosis on the presence or absence of a joint bleed with a low likelihood of imaging artifact incorrectly demonstrating or missing pathology.</p> <p>In clinical practice, POCUS images are seldom stored for future review or comparison <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_038">38</a>]</sup>. This process has been questioned as it limits the possibility of performing quality assurance audits and does not acknowledge the importance of reviewing serial scans to assess for the evolution/resolution of pathology <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_038">38</a>]</sup>. To be consistent with this process and to maintain the independence of POCUS scans, the current study blinded the physiotherapist and the sonographer to the images and findings from previous scans. However, given the evolution of blood on ultrasound, the potential for underlying joint arthropathy in PwH, and the role of normal physiologic fluid in synovial joints, it may be important for the POCUS operator to have access to previous POCUS scans. Being able to access previous images can facilitate analysis of the clinical evolution of pathology and physiologic fluid, which may have implications on the level of agreement between the trained physiotherapist and sonographer as there may be variations in agreement at different stages of recovery. Also, recording previous images may decrease health care costs. If the POCUS scans are done with similar standards as diagnostic imaging, accessing stored images may avoid the need for repeat scans if clinical questions arise that may require consultation with radiology. These considerations may have implications for education and clinical practice and will be important areas for future study.</p> <p>The current study had a number of strengths. The physiotherapist was trained to a set standard for this specific application of POCUS by an accredited academic institution. Both the physiotherapist and the sonographer were blinded and were provided with a standardised scanning protocol, with the order of assessment randomised based on clinician availability. Both the physiotherapist and the sonographer used the same ultrasound machine and after each POCUS scan the machine was returned to the main screen to maintain blinding and the independence of scans. All 13 participants recruited into the study attended all study visits. Lastly, the study procedures were consistent with the traditional pathway in diagnostic imaging. The study was designed in this manner to ensure that the same quality and standard of care was provided in the clinic setting.</p> <p>Although this is a pilot study, its main limitations are the small sample size and inclusion of a single physiotherapist and sonographer, both of which may impact generalisability. While the results suggests that a short training programme provided the physiotherapist with an appropriate level of education and training in the performance, acquisition, and interpretation of POCUS scans in PwH, this needs to be replicated with physiotherapists and sonographers with varying levels of training and experience. It would be interesting to compare the competencies of sonographers with no musculoskeletal experience to physiotherapists who have completed POCUS training specific to the musculoskeletal system. Future inter-professional agreement studies should also consider including other members of the haemophilia comprehensive care team, such as physicians/haematologists and nurses, who may be using POCUS in clinical practice. In addition, with the decreasing annualised bleeding rates in PwH <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_039">39</a>]</sup>, a multi-centre trial would be needed to obtain a sufficient number of suspected bleeding episodes for a definitive study.</p> <p>This study focused on hinge joints of the knee, ankle, and elbow, which account for the majority of haemarthrosis in PwH and are easily accessible with relatively simple POCUS scanning protocols. Future research would need to look at the inter-professional agreement and image quality for more complex joints, such as the ball-and-socket joints (i.e. shoulder and hip). Although haemarthrosis could occur in patients with other musculoskeletal injuries, these results should only be applied to the assessment of haemarthrosis in patients with haemophilia <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_040">40</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_041">41</a>,<a ref-type="bibr" href="#j_jhp-2022-0008_ref_042">42</a>]</sup>. The protocol and training received by the physiotherapist in this study was specific to haemophilia and it is important to remember that one of the downsides of POCUS occurs when users extrapolate beyond their protocol and training <sup>[<a ref-type="bibr" href="#j_jhp-2022-0008_ref_013">13</a>]</sup>. Generalising the findings of this study to patients with other conditions should therefore be done with caution. However, this study does demonstrate that within a relatively short period of formal training, including both didactic and practical curricula, physiotherapists can become proficient in POCUS. Given their background knowledge in anatomy and physiology, this study lends support for physiotherapists to be trained to use POCUS with different patient populations and conditions.</p> </sec> <sec id="j_jhp-2022-0008_s_005"><div>CONCLUSION</div> <p>Optimal image quality and an excellent level of agreement between the physiotherapist and sonographer-performed POCUS for the assessment of acute haemarthrosis in people with haemophilia A and B was observed. This pilot study found that a physiotherapist who received appropriate training in the McMaster University Mohawk College Training Program can perform and interpret POCUS scans for the assessment of acute haemarthrosis to a level that is comparable to an experienced sonographer. Further investigation is warranted.</p> </sec> </div></div></div></div><div id="pane-4" class="SeriesTab_card__26XnC SeriesTab_tab-pane__3pc7y card tab-pane" role="tabpanel" aria-labelledby="tab-4"><div class="SeriesTab_card-header__1DTAS card-header d-md-none pl-0" role="tab" id="heading-4"><h4 class="mb-0"><a data-toggle="collapse" href="#collapse-4" data-parent="#content" aria-expanded="false" aria-controls="collapse-4" style="padding:24px 0">Figure e tabelle<svg aria-hidden="true" focusable="false" data-prefix="fas" data-icon="chevron-down" class="svg-inline--fa fa-chevron-down fa-w-14 " role="img" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 448 512"><path fill="currentColor" d="M207.029 381.476L12.686 187.132c-9.373-9.373-9.373-24.569 0-33.941l22.667-22.667c9.357-9.357 24.522-9.375 33.901-.04L224 284.505l154.745-154.021c9.379-9.335 24.544-9.317 33.901.04l22.667 22.667c9.373 9.373 9.373 24.569 0 33.941L240.971 381.476c-9.373 9.372-24.569 9.372-33.942 0z"></path></svg></a></h4></div><div id="collapse-4" class="SeriesTab_seriesTabCollapse__2csiF collapse" role="tabpanel" aria-labelledby="heading-4" data-parent="#content"><div class="SeriesTab_series-tab-body__1tZ1H SeriesTab_card-body__31JEh card-body Article_figures-tables__2SC5X"><figure><h4 class="mb-4"></h4><img src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_011.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=7aa18200981337166cb758b459caba9ef30949a8c8bd6022b6f0324cfa0da3d4" alt="With appropriate training, physiotherapists can perform and interpret point-of-care ultrasound scans for the assessment of acute haemarthrosis to a level comparable to an experienced sonographer© Shutterstock" class="mw-100"/><figcaption class="fw-500">With appropriate training, physiotherapists can perform and interpret point-of-care ultrasound scans for the assessment of acute haemarthrosis to a level comparable to an experienced sonographer© Shutterstock</figcaption></figure><figure><h4 class="mb-4">Figure 1</h4><img src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_001.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=a5a0f64f26611498b0566caf9a4fbc77d86eeb4cb5918469ff7140707047a942" alt="Patient position and transducer orientation for posterior elbow joint recess" class="mw-100"/><figcaption class="fw-500">Patient position and transducer orientation for posterior elbow joint recess</figcaption></figure><figure><h4 class="mb-4">Figure 2</h4><img src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_002.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=07bce862d05513dd6f6df5bc878b7fc9e543ea3d0350862e6edb66d2c40d0592" alt="Right elbow, posterior joint recess in long axis with overlying triceps tendon" class="mw-100"/><figcaption class="fw-500">Right elbow, posterior joint recess in long axis with overlying triceps tendon</figcaption></figure><figure><h4 class="mb-4">Figure 3</h4><img src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_003.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=b0f1ab3adf9fec52e6b8a92ce5f8a24c2fbcb61a5a7d0c77a466b9ee4cea188b" alt="Patient position and transducer orientation for suprapatellar anterior joint recess" class="mw-100"/><figcaption class="fw-500">Patient position and transducer orientation for suprapatellar anterior joint recess</figcaption></figure><figure><h4 class="mb-4">Figure 4</h4><img src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_004.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=1928096bee31d30de254e4876ec307e25261669a9a9910db58501d9fd5fb4fcc" alt="Right knee, suprapatellar anterior joint recess" class="mw-100"/><figcaption class="fw-500">Right knee, suprapatellar anterior joint recess</figcaption></figure><figure><h4 class="mb-4">Figure 5</h4><img src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_005.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=9664b6de4f5d07bd8faa09f89e6372882f9a81f4f2309a4f376c18b63f63274d" class="mw-100"/><figcaption class="fw-500"></figcaption></figure><figure><h4 class="mb-4">Figure 6</h4><img src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_006.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=b81e1ecc08dbcabc2679f654939083eb5696953afc1453496c689839dae3bf09" class="mw-100"/><figcaption class="fw-500"></figcaption></figure><figure><h4 class="mb-4">Figure 7</h4><img src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_007.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=28e9423fbf92acc340ac71a2f3da65815e5c94d9bb997c7b409a04dd90cfccf8" class="mw-100"/><figcaption class="fw-500"></figcaption></figure><figure><h4 class="mb-4">Figure 8</h4><img src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_008.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=2ed00e107e965b0312fc89742177c5a5cf02676973e29e79194b7ec2b9439991" class="mw-100"/><figcaption class="fw-500"></figcaption></figure><figure><h4 class="mb-4">Figure 9</h4><img src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_009.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=0dc883e3698a24898eb99455e67b0c88b32fa7a9dcf0a61bd43c9cb1e83fad4d" alt="Patient position and transducer orientation for anterior tibiotalar joint recess" class="mw-100"/><figcaption class="fw-500">Patient position and transducer orientation for anterior tibiotalar joint recess</figcaption></figure><figure><h4 class="mb-4">Figure 10</h4><img src="https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_010.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20220816T122539Z&X-Amz-SignedHeaders=host&X-Amz-Expires=18000&X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request&X-Amz-Signature=ec1204564bae5c2039d436add9cd7c63277fcc7839654e94e14a18b64b407d5a" alt="Right tibiotalar joint, anterior joint recess in sagittal plane with overlying anterior tibialis tendon" class="mw-100"/><figcaption class="fw-500">Right tibiotalar joint, anterior joint recess in sagittal plane with overlying anterior tibialis tendon</figcaption></figure><h4 class="mb-4 mt-4">Quality of ultrasound images</h4><table frame="hsides" rules="all"> <thead> <tr> <th align="left" valign="bottom" rowspan="2"/> <th align="center" valign="bottom" colspan="3"><bold>QUALITY OF ULTRASOUND IMAGES</bold></th> </tr> <tr> <th align="left" valign="bottom"><bold>OPTIMAL</bold></th> <th align="left" valign="bottom"><bold>ACCEPTABLE</bold></th> <th align="left" valign="bottom"><bold>SUB-OPTIMAL</bold></th> </tr> </thead> <tbody> <tr> <td align="left" valign="top">Physiotherapist</td> <td align="left" valign="top">84.6%</td> <td align="left" valign="top">15.4%</td> <td align="left" valign="top">0%</td> </tr> <tr> <td align="left" valign="top">Sonographer</td> <td align="left" valign="top">88.9%</td> <td align="left" valign="top">11.1%</td> <td align="left" valign="top">0%</td> </tr> </tbody> </table><h4 class="mb-4 mt-4">Level of agreement on the presence or absence of blood within the joint</h4><table frame="hsides" rules="cols"> <thead> <tr> <th align="left" valign="top"/> <th align="left" valign="top"><bold>KAPPA COEFFICIENT</bold></th> <th align="left" valign="top"><bold>AGREEMENT</bold></th> </tr> <tr> <th align="left" valign="top" colspan="3"><hr/></th> </tr> </thead> <tbody> <tr> <td align="left" valign="top">Overall (n= 36)</td> <td align="left" valign="top">k=0.80 (95% CI, 0.59–1.00) p=0.000</td> <td align="left" valign="top">Prevalence: 70.8%<break/>OA: 91.7%<break/>SPA: 94.1%<break/>SNA: 85.7%</td> </tr> </tbody> </table></div></div></div><div id="reference" class="SeriesTab_card__26XnC SeriesTab_tab-pane__3pc7y card tab-pane" role="tabpanel" aria-labelledby="tab-5"><div class="SeriesTab_card-header__1DTAS card-header d-md-none pl-0" role="tab" id="heading-5"><h4 class="mb-0"><a data-toggle="collapse" href="#collapse-5" data-parent="#content" aria-expanded="false" aria-controls="collapse-5" style="padding:24px 0">Riferimenti<svg aria-hidden="true" focusable="false" data-prefix="fas" data-icon="chevron-down" class="svg-inline--fa fa-chevron-down fa-w-14 " role="img" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 448 512"><path fill="currentColor" d="M207.029 381.476L12.686 187.132c-9.373-9.373-9.373-24.569 0-33.941l22.667-22.667c9.357-9.357 24.522-9.375 33.901-.04L224 284.505l154.745-154.021c9.379-9.335 24.544-9.317 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Practice\u003c/em\u003e is covered by the following services: \u003c/p\u003e \u003cul\u003e \u003cli\u003e Baidu Scholar \u003c/li\u003e \u003cli\u003e Cabell's Whitelist \u003c/li\u003e \u003cli\u003e CNKI Scholar (China National Knowledge Infrastructure) \u003c/li\u003e \u003cli\u003e CNPIEC - cnpLINKer \u003c/li\u003e \u003cli\u003e Dimensions \u003c/li\u003e \u003cli\u003e EBSCO \u003c/li\u003e \u003cli\u003e ExLibris \u003c/li\u003e \u003cli\u003e Google Scholar \u003c/li\u003e \u003cli\u003e J-Gate \u003c/li\u003e \u003cli\u003e JournalTOCs \u003c/li\u003e \u003cli\u003e KESLI-NDSL (Korean National Discovery for Science Leaders) \u003c/li\u003e \u003cli\u003e MyScienceWork \u003c/li\u003e \u003cli\u003e Naver Academic \u003c/li\u003e \u003cli\u003e Naviga (Softweco) \u003c/li\u003e \u003cli\u003e QOAM (Quality Open Access Market) \u003c/li\u003e \u003cli\u003e ReadCube \u003c/li\u003e \u003cli\u003e Semantic Scholar \u003c/li\u003e \u003cli\u003e TDNet \u003c/li\u003e \u003cli\u003e WorldCat (OCLC) \u003c/li\u003e \u003cli\u003e X-MOL \u003c/li\u003e \u003c/ul\u003e"},{"type":"abstracting-and-indexing","language":"German","textformat":null,"content":"\u003cp\u003e \u003cem\u003eThe Journal of Haemophilia Practice\u003c/em\u003e ist in den folgenden Services indiziert: \u003c/p\u003e \u003cul\u003e \u003cli\u003e Baidu Scholar \u003c/li\u003e \u003cli\u003e Cabell's Whitelist \u003c/li\u003e \u003cli\u003e CNKI Scholar (China National Knowledge Infrastructure) \u003c/li\u003e \u003cli\u003e CNPIEC - cnpLINKer \u003c/li\u003e \u003cli\u003e Dimensions \u003c/li\u003e \u003cli\u003e EBSCO \u003c/li\u003e \u003cli\u003e ExLibris \u003c/li\u003e \u003cli\u003e Google Scholar \u003c/li\u003e \u003cli\u003e J-Gate \u003c/li\u003e \u003cli\u003e JournalTOCs \u003c/li\u003e \u003cli\u003e KESLI-NDSL (Korean National Discovery for Science Leaders) \u003c/li\u003e \u003cli\u003e MyScienceWork \u003c/li\u003e \u003cli\u003e Naver Academic \u003c/li\u003e \u003cli\u003e Naviga (Softweco) \u003c/li\u003e \u003cli\u003e QOAM (Quality Open Access Market) \u003c/li\u003e \u003cli\u003e ReadCube \u003c/li\u003e \u003cli\u003e Semantic Scholar \u003c/li\u003e \u003cli\u003e TDNet \u003c/li\u003e \u003cli\u003e WorldCat (OCLC) \u003c/li\u003e \u003cli\u003e X-MOL \u003c/li\u003e \u003c/ul\u003e"},{"type":"advantages","language":"English","textformat":null,"content":"\u003cP\u003e\u003cSTRONG\u003eThe Journal of Haemophilia Practice\u003c/STRONG\u003e is an international, open-access, peer-reviewed journal that accepts papers from all members of the multidisciplinary bleeding disorders care team.\u003cBR\u003eAny manuscript that is relevant to current haemophilia practice will be considered for publication by our editorial review team. To this end, we positively welcome: \u003c/P\u003e \u003cUL\u003e \u003cUL\u003e \u003cP\u003e\u003c/P\u003e\u003c/UL\u003e \u003cLI\u003eOriginal research \u003c/LI\u003e \u003cLI\u003eCase reports \u003c/LI\u003e \u003cLI\u003eCase Series \u003c/LI\u003e \u003cLI\u003eReviews in any field of bleeding disorders that are of relevance to current clinical practice \u003c/LI\u003e \u003cLI\u003eClinical Updates that describe current advances in any clinical field related to bleeding disorders \u003c/LI\u003e \u003cLI\u003eEditorials that address a particular topic of current interest. \u003c/LI\u003e \u003cUL\u003e \u003cP\u003e\u003c/P\u003e\u003c/UL\u003e\u003c/UL\u003e \u003cP\u003eAll manuscripts submitted to The Journal of Haemophilia Practice will first be subject to a technical review, including a quality check of all the files submitted, including tables, figures and references. This will include a plagiarism check (see below). Manuscripts will then be reviewed by the Editor-in-Chief, who will decide whether or not to proceed to peer-review by members of our editorial board and invited experts. The identity of the reviewers will not be disclosed to the authors. The review procedure will result in one of three decisions: \u003c/P\u003e \u003cUL\u003e \u003cUL\u003e \u003cP\u003e\u003c/P\u003e\u003c/UL\u003e \u003cLI\u003eAccept \u003c/LI\u003e \u003cLI\u003eAccept subject to revision \u003c/LI\u003e \u003cLI\u003eReject \u003c/LI\u003e \u003cUL\u003e \u003cP\u003e\u003c/P\u003e\u003c/UL\u003e\u003c/UL\u003e \u003cP\u003eThe editorial decision will be communicated to the authors as soon as the review process has been finalized. In case of revisions, the revised article will be sent to the reviewers who will decide on a new recommendation for revision, acceptance or rejection. \u003c/P\u003e \u003cP\u003eThe estimated time from the submission to first decision is approximately 4-6 weeks, and from the final revision to acceptance is approximately 2 weeks. Prior to publication, the corresponding author will receive a proof of their article in order to confirm the accuracy of the text or suggest modifications. \u003c/P\u003e \u003cP\u003e“The Journal of Haemophilia Practice” is a double-blind peer reviewed journal. The journal has no article processing charges (APCs) nor article submission charges. \u003c/P\u003e \u003cP\u003e\u003c/P\u003e \u003cP\u003e\u003cSTRONG\u003eArchiving\u003c/STRONG\u003e \u003c/P\u003e \u003cP\u003eSciendo archives the contents of this journal in \u003cA href=\"https://www.portico.org/\"\u003ePortico\u003c/A\u003e - digital long-term preservation service of scholarly books, journals and collections. \u003c/P\u003e \u003cP\u003e\u003cSTRONG\u003ePlagiarism Policy\u003c/STRONG\u003e \u003c/P\u003e \u003cP\u003eThe editorial board is participating in a growing community of \u003cA href=\"https://www.crossref.org/services/similarity-check/\"\u003eSimilarity Check System's\u003c/A\u003e users in order to ensure that the content published is original and trustworthy. Similarity Check is a medium that allows for comprehensive manuscripts screening, aimed to eliminate plagiarism and provide a high standard and quality peer-review process. \u003c/P\u003e"},{"type":"editorial","language":"English","textformat":null,"content":"\u003cP\u003e\u003cSTRONG\u003eEditor-in-Chief\u003c/STRONG\u003e\u003cBR\u003eDr Kate Khair, Great Ormond Street Hospital, London, UK \u003c/P\u003e \u003cP\u003e\u003cSTRONG\u003eManaging Editor\u003cBR\u003e\u003c/STRONG\u003eMike Holland, Haemnet, UK \u003cBR\u003e\u003cA href=\"mailto:mike@haemnet.com\"\u003emike@haemnet.com\u003c/A\u003e \u003c/P\u003e \u003cP\u003e\u003cSTRONG\u003eEditorial Advisory Board\u003cBR\u003e\u003c/STRONG\u003eTami Barazani-Brutman, Sheba Medical Center at Sheba, Tel Hashomer Hospital, Israel\u003cBR\u003ePaul Batty, Queen Mary University of London, UK, and Queen’s University, Ontario, Canada\u003cBR\u003eGreig Blamey, Health Sciences Center, University of Alberta, Canada\u003cBR\u003eErica Crilly, British Columbia Children's Hospital, Vancouver, Canada\u003cBR\u003eJanine Furmedge, The Royal Children’s Hospital Haemophilia Centre, Melbourne, Australia\u003cBR\u003eRich Gorman, Brighton and Sussex Medical School, UK\u003cBR\u003eChris Guelcher, Children’s National Hospital, Washington, USA\u003cBR\u003eChris Harrington, Royal Free Hospital, London, UK\u003cBR\u003eCathy Harrison, Sheffield Haemophilia \u0026amp; Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK\u003cBR\u003eDan Hart, The Royal London Hospital and Barts Health NHS Trust, London, UK\u003cBR\u003eAdam Jones, University of Sunderland, UK\u003cBR\u003eRadek Kaczmarek, Indiana University School of Medicine, USA\u003cBR\u003eSebastien Lobet, Cliniques Universitaires Saint-Luc, Brussels, Belgium\u003cBR\u003ePaul McLaughlin, Royal Free Hospital, London, UK\u003cBR\u003eGreta Mulders, Erasmus University Medical Center, Rotterdam, The Netherlands\u003cBR\u003eJames Munn, University of Michigan Hemophilia and Coagulation Disorders Program, Michigan, USA\u003cBR\u003eDeclan Noone, European Haemophilia Association, Brussels\u003cBR\u003eJamie O'Hara, University of Chester, Cheshire, UK\u003cBR\u003eDebra Pollard, Royal Free Hospital, London, UK\u003cBR\u003eBJ Ramsay, Wellington Haemophilia Centre, Wellington, New Zealand\u003cBR\u003eDakota J. Rosenfelt, PharmD, Missouri, US\u003cBR\u003eSylvia von Mackensen, Institute of Medical Psychology at the University Medical Centre, Hamburg, Germany\u003cBR\u003eLinda Myrin Westesson, Sahlgrenska University Hospital, Gothenburg, Sweden\u003cBR\u003eMichelle Witkop, National Hemophilia Foundation, USA \u003c/P\u003e \u003cP\u003e\u003cSTRONG\u003eTechnical Editor\u003cBR\u003e\u003c/STRONG\u003eKathryn Jenner, Haemnet, UK \u003c/P\u003e \u003cP\u003e\u003cSTRONG\u003ePublisher\u003c/STRONG\u003e\u003cBR\u003eDe Gruyter Poland\u003cBR\u003eBogumiła Zuga 32A Str.\u003cBR\u003e01-811 Warsaw, Poland\u003cBR\u003eT: +48 22 701 50 15 \u003c/P\u003e"},{"type":"submission","language":"English","textformat":null,"content":"\u003cDIV align=left\u003e \u003cP\u003eManuscripts should be submitted via the journal’s Scholar One Manuscripts site: \u003cA href=\"http://mc04.manuscriptcentral.com/jhaempract\"\u003emc04.manuscriptcentral.com/jhaempract\u003c/A\u003e. \u003c/P\u003e \u003cP\u003eYou will need to log in. If you are using Scholar One for the first time, use the ‘Create an Account’ link. \u003c/P\u003e \u003cP\u003eOne you have logged in, select the ‘Author’ tab. You should then follow the on-screen instructions – the system will guide you through the process of manuscript submission. Alongside the manuscript, accompanying figures and tables, and general information about the manuscript, you will be asked to provide: \u003c/P\u003e \u003cUL\u003e \u003cLI\u003eThe names of suggested reviewers (optional) \u003c/LI\u003e \u003cLI\u003eA cover letter signed on behalf of all co-authors by the corresponding author \u003c/LI\u003e \u003cLI\u003eAn Open Access License agreement, completed by the corresponding author on behalf of all co-authors (available via the ‘Instructions and Forms’ tab on the journal’s Scholar One Manuscripts site: \u003cA href=\"http://mc04.manuscriptcentral.com/jhaempract\"\u003emc04.manuscriptcentral.com/jhaempract\u003c/A\u003e) \u003c/LI\u003e \u003cLI\u003eDetails of any conflicts of interest \u003c/LI\u003e \u003cLI\u003eConfirmation that informed consent has been obtained where appropriate. \u003c/LI\u003e\u003c/UL\u003e \u003cP\u003e\u003c/P\u003e \u003cP\u003eAfter submitting your manuscript, you will receive a confirmation email. \u003c/P\u003e \u003cP\u003eYou can check on the status of your manuscript at any time by logging in to your Scholar One account. \u003c/P\u003e \u003cP\u003eThe journal will notify you by email when a decision has been made on your manuscript. \u003c/P\u003e \u003cP\u003e\u003cSTRONG\u003eManuscript types\u003c/STRONG\u003e \u003c/P\u003e \u003cP\u003eThe Journal of Haemophilia Practice accepts \u003c/P\u003e \u003cUL\u003e \u003cLI\u003eOriginal research \u003c/LI\u003e \u003cLI\u003eCase reports \u003c/LI\u003e \u003cLI\u003eCase series \u003c/LI\u003e \u003cLI\u003eReviews in any field of bleeding disorders of relevance to current clinical practice \u003c/LI\u003e \u003cLI\u003eClinical Updates that describe current advances in any clinical field related to bleeding disorders \u003c/LI\u003e \u003cLI\u003eEditorials that address a particular topic of current interest. \u003c/LI\u003e\u003c/UL\u003e \u003cP\u003e\u003c/P\u003e \u003cP\u003ePlease note that case reports should meet the standards outlined in the \u003cA href=\"https://www.care-statement.org/\"\u003eCARE Case Report Guidelines\u003c/A\u003e. Authors submitting case reports are advised to consult the \u003cA href=\"https://www.care-statement.org/checklist\"\u003eCARE Checklist\u003c/A\u003e. \u003c/P\u003e \u003cP\u003e\u003cSTRONG\u003eManuscript format\u003c/STRONG\u003e \u003c/P\u003e \u003cP\u003e\u003cU\u003eWordcount\u003c/U\u003e \u003c/P\u003e \u003cP\u003eAlthough we do not specify wordcounts for articles, we recommend the following: \u003c/P\u003e \u003cUL\u003e \u003cLI\u003eFor shorter papers, e.g. case reports and small cohort studies: 1,000–3,000 words \u003c/LI\u003e \u003cLI\u003eFor reviews, larger studies and qualitative studies, which require explanation of methodologies: 3,000–7,000 words. \u003c/LI\u003e\u003c/UL\u003e \u003cP\u003e\u003c/P\u003e \u003cP\u003e\u003cU\u003eTitle\u003c/U\u003e \u003c/P\u003e \u003cP\u003eThe title should be short and informative. For case reports, the words ‘case report’ should be included in the title. \u003c/P\u003e \u003cP\u003e\u003cU\u003eAuthors\u003c/U\u003e \u003c/P\u003e \u003cP\u003eFull author names and affiliation should be given. An ORCID iD for each author should be provided where available. \u003c/P\u003e \u003cP\u003e\u003cU\u003eAbstract\u003c/U\u003e \u003c/P\u003e \u003cP\u003eFor original articles, a short abstract should be provided using the following headings: Background or Introduction, Aims, Methods, Results, Conclusion. \u003c/P\u003e \u003cP\u003e\u003cU\u003eKeywords\u003c/U\u003e \u003c/P\u003e \u003cP\u003eSubmissions should include 3–6 keywords for indexing purposes. \u003c/P\u003e \u003cP\u003e\u003cU\u003eReference style\u003c/U\u003e \u003c/P\u003e \u003cP\u003eJournal titles should be abbreviated according to the style of Index Medicus and spelled out in full if not listed in Index Medicus. These can be looked up in the \u003cA href=\"https://www.ncbi.nlm.nih.gov/nlmcatalog/journals\"\u003eNLM Catalog\u003c/A\u003e. \u003c/P\u003e \u003cP\u003eThe DOI (digital object identifier) associated with journal articles should be provided where available. \u003c/P\u003e \u003cP\u003eWhere there are six or more authors associated with a reference, the first three should be listed, followed by ‘et al.’ \u003c/P\u003e \u003cP\u003eDatasets should be cited using the format outlined by the \u003cA href=\"https://www.force11.org/datacitationprinciples\"\u003eJoint Declaration of Data Citation Principles\u003c/A\u003e: Authors; Year; Dataset title; Data repository/archive; Version (if relevant); Persistent identifier, e.g. DOI (if available). \u003c/P\u003e \u003cP\u003e\u003cEM\u003eReference style examples:\u003c/EM\u003e \u003c/P\u003e \u003cUL\u003e \u003cLI\u003eReference to an article: \u003c/LI\u003e\u003c/UL\u003e \u003cP\u003e\u003c/P\u003e \u003cP\u003eKhair K, Klukowska A, Myrin Westesson L, et al. The burden of bleeds and other clinical determinants on caregivers of children with haemophilia (the BBC Study). Haemophilia 2019; 25(3): 416-423. doi: 10.1111/hae.13736. \u003c/P\u003e \u003cUL\u003e \u003cLI\u003eReference to a book: \u003c/LI\u003e\u003c/UL\u003e \u003cP\u003e\u003c/P\u003e \u003cP\u003eJones P. Living with Haemophilia. 2002. Oxford: Oxford University Press. \u003c/P\u003e \u003cUL\u003e \u003cLI\u003eReference to a chapter in a book: \u003c/LI\u003e\u003c/UL\u003e \u003cP\u003e\u003c/P\u003e \u003cP\u003eEscobar MA, Roberts HR. Less common congenital disorders of hemostasis. In: Kitchens CS, ed. Consultative Hemostasis and Thrombosis, 3rd edn. 2013. Philadelphia, PA: W.B. Saunders Company. \u003c/P\u003e \u003cUL\u003e \u003cLI\u003eReference to a webpage/online resource: \u003c/LI\u003e\u003c/UL\u003e \u003cP\u003e\u003c/P\u003e \u003cP\u003eEuropean Medicines Agency (EMA). European Public Assessment Report (EPAR) NovoSeven Summary for the Public. 2009. Available from http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/medicines/000074/human_med_000936.jsp\u0026amp;mid=WC0b01ac058001d124 (accessed 9 September 2013). \u003c/P\u003e \u003cP\u003e\u003c/P\u003e \u003cP\u003e\u003cU\u003eFigures and tables\u003c/U\u003e \u003c/P\u003e \u003cP\u003ePlease provide tables and figures at the end of the manuscript or as a separate file. \u003c/P\u003e \u003cP\u003e\u003cSTRONG\u003eInformed consent\u003c/STRONG\u003e \u003c/P\u003e \u003cP\u003ePeople who are reported in studies have a right to privacy that should not be violated without informed consent. Identifying information, including names, initials, dates of birth or hospital numbers, should not be published in written descriptions, photographs or pedigrees unless the information is essential for scientific purposes and the person (or parent or guardian) gives written informed consent for publication. \u003c/P\u003e \u003cP\u003eInformed consent for this purpose requires that an identifiable person be shown the manuscript to be submitted for publication. Authors should disclose to these participants whether any potential identifiable material might be available via the internet or in print after publication. \u003c/P\u003e \u003cP\u003eEach implicated individual’s consent should be written and archived with the authors. If the patient is a minor or lacks capacity to consent, the written informed consent of a parent or guardian must be given. If the person in the case study is deceased, written consent must be sought from a relative. Without consent, a case report may be considered for publication if the patient is sufficiently anonymised according to \u003cA href=\"http://www.icmje.org/recommendations/\"\u003eICMJE guidelines\u003c/A\u003e. Nonessential identifying details should always be omitted. Informed consent should be obtained if there is any doubt that anonymity can be maintained. For example, masking the eye region in photographs of patients is inadequate protection of anonymity. \u003c/P\u003e \u003cP\u003eConsent must be mentioned in the manuscript. We reserve the right to request copies of consent documentation. The Editor will make the final determination of what constitutes personally identifiable information on a case-by-case basis. \u003c/P\u003e \u003cP\u003e\u003cSTRONG\u003eOpen Access Statement\u003c/STRONG\u003e \u003c/P\u003e \u003cP\u003eThe journal is an Open Access journal that allows a free unlimited access to all its contents without any restrictions upon publication to all users. \u003c/P\u003e \u003cP\u003e\u003cSTRONG\u003e\u003cA href=\"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/JHP/Open_Access_License.pdf\"\u003eOpen Access License\u003c/A\u003e\u003c/STRONG\u003e \u003c/P\u003e\u003c/DIV\u003e"}]}],"metrics":"","pricing":null,"publicationFrequency":{"frequency":"1","period":"YEAR"},"permissions":null,"contributors":"","serial":null,"publishMonth":"1","publishYear":"2022","tableCount":null,"figureCount":null,"refCount":null,"keywords":[],"figures":null,"tables":null,"planPubDates":[],"epubLink":null,"pdfLink":null,"coverImage":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/cover-image.jpg","coverImageOriginal":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/cover-image-original.jpg","pdfFiles":[],"parentObjectId":"6228ac980d198124537d1d3b","isParentConference":false,"relatedTitles":null,"forAuthors":null,"nextPackageId":"628812768b5f78544d96b005","prevPackageId":"62513a1274dac469fb47c45b","parentName":"Volume 9 (2022): Issue 1 (January 2022)","grandParentId":"6005b891e797941b18f24f3f","grandParentName":"The Journal of Haemophilia Practice","isGrandParentConference":false,"publisherName":"Sciendo","publisherLocation":null,"nextMap":{"id":{"timestamp":1653084790,"date":"2022-05-20T22:13:10.000+00:00"},"doi":"10.2478/jhp-2022-0009"},"prevMap":{"id":{"timestamp":1653084789,"date":"2022-05-20T22:13:09.000+00:00"},"doi":"10.2478/jhp-2022-0007"},"counter":0,"apaString":"Strike,K.,Chan,A.,Maly,M.,Stein,N.,Farrell,L. \u0026 Solomon,P.(2022).\u003carticle-title\u003ePoint of care ultrasonography in patients with haemophilia and acute haemarthrosis: a physiotherapist and sonographer inter-professional agreement pilot study\u003c/article-title\u003e. 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Outcome measures in Haemophilia: Beyond ABR (Annualized Bleeding Rate). \u003citalic\u003eHaemophilia\u003c/italic\u003e 2021; 27 Suppl 3: 87–95. doi: \u003cpub-id pub-id-type=\"doi\"\u003e10.1111/hae.14099\u003c/pub-id\u003e.\u003c/mixed-citation\u003e\n\u003celement-citation publication-type=\"journal\" publication-format=\"print\"\u003e\n\u003cname\u003e\u003csurname\u003eManco-Johnson\u003c/surname\u003e\u003cgiven-names\u003eMJ\u003c/given-names\u003e\u003c/name\u003e\n\u003cname\u003e\u003csurname\u003eWarren\u003c/surname\u003e\u003cgiven-names\u003eBB\u003c/given-names\u003e\u003c/name\u003e\n\u003cname\u003e\u003csurname\u003eBuckner\u003c/surname\u003e\u003cgiven-names\u003eTW\u003c/given-names\u003e\u003c/name\u003e\n\u003cname\u003e\u003csurname\u003eFunk\u003c/surname\u003e\u003cgiven-names\u003eSM\u003c/given-names\u003e\u003c/name\u003e\n\u003cname\u003e\u003csurname\u003eWang\u003c/surname\u003e\u003cgiven-names\u003eM\u003c/given-names\u003e\u003c/name\u003e\n\u003carticle-title\u003eOutcome measures in Haemophilia: Beyond ABR (Annualized Bleeding Rate)\u003c/article-title\u003e\n\u003csource\u003eHaemophilia\u003c/source\u003e\n\u003cyear\u003e2021\u003c/year\u003e\n\u003cvolume\u003e27\u003c/volume\u003e\n\u003cissue\u003eSuppl 3\u003c/issue\u003e\n\u003cfpage\u003e87\u003c/fpage\u003e\n\u003clpage\u003e95\u003c/lpage\u003e\n\u003cpub-id pub-id-type=\"doi\"\u003e10.1111/hae.14099\u003c/pub-id\u003e\n\u003c/element-citation\u003e\n\u003c/ref\u003e"},{"refId":"j_jhp-2022-0008_ref_040","citeString":"Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: Part II. Differential diagnosis. Am Fam Physician 2003; 68(5): 917–22.","doi":null,"mixed-citation":"\u003cref id=\"j_jhp-2022-0008_ref_040\"\u003e\u003clabel\u003e40\u003c/label\u003e\n\u003cmixed-citation\u003eCalmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: Part II. Differential diagnosis. \u003citalic\u003eAm Fam Physician\u003c/italic\u003e 2003; 68(5): 917–22.\u003c/mixed-citation\u003e\n\u003celement-citation publication-type=\"journal\" publication-format=\"print\"\u003e\n\u003cname\u003e\u003csurname\u003eCalmbach\u003c/surname\u003e\u003cgiven-names\u003eWL\u003c/given-names\u003e\u003c/name\u003e\n\u003cname\u003e\u003csurname\u003eHutchens\u003c/surname\u003e\u003cgiven-names\u003eM\u003c/given-names\u003e\u003c/name\u003e\n\u003carticle-title\u003eEvaluation of patients presenting with knee pain: Part II. Differential diagnosis\u003c/article-title\u003e\n\u003csource\u003eAm Fam Physician\u003c/source\u003e\n\u003cyear\u003e2003\u003c/year\u003e\n\u003cvolume\u003e68\u003c/volume\u003e\n\u003cissue\u003e5\u003c/issue\u003e\n\u003cfpage\u003e917\u003c/fpage\u003e\n\u003clpage\u003e22\u003c/lpage\u003e\n\u003c/element-citation\u003e\n\u003c/ref\u003e"},{"refId":"j_jhp-2022-0008_ref_041","citeString":"Iobst CA, Stanitski CL. Acute knee injuries. Clin Sports Med 2000; 19(4): 621–35, vi. doi: 10.1016/s0278-5919(05)70229-5.","doi":"10.1016/s0278-5919(05)70229-5","mixed-citation":"\u003cref id=\"j_jhp-2022-0008_ref_041\"\u003e\u003clabel\u003e41\u003c/label\u003e\n\u003cmixed-citation\u003eIobst CA, Stanitski CL. Acute knee injuries. \u003citalic\u003eClin Sports Med\u003c/italic\u003e 2000; 19(4): 621–35, vi. doi: \u003cpub-id pub-id-type=\"doi\"\u003e10.1016/s0278-5919(05)70229-5\u003c/pub-id\u003e.\u003c/mixed-citation\u003e\n\u003celement-citation publication-type=\"journal\" publication-format=\"print\"\u003e\n\u003cname\u003e\u003csurname\u003eIobst\u003c/surname\u003e\u003cgiven-names\u003eCA\u003c/given-names\u003e\u003c/name\u003e\n\u003cname\u003e\u003csurname\u003eStanitski\u003c/surname\u003e\u003cgiven-names\u003eCL\u003c/given-names\u003e\u003c/name\u003e\n\u003carticle-title\u003eAcute knee injuries\u003c/article-title\u003e\n\u003csource\u003eClin Sports Med\u003c/source\u003e\n\u003cyear\u003e2000\u003c/year\u003e\n\u003cvolume\u003e19\u003c/volume\u003e\n\u003cissue\u003e4\u003c/issue\u003e\n\u003cfpage\u003e621\u003c/fpage\u003e\n\u003clpage\u003e35\u003c/lpage\u003e\n\u003cfpage\u003evi\u003c/fpage\u003e\n\u003cpub-id pub-id-type=\"doi\"\u003e10.1016/s0278-5919(05)70229-5\u003c/pub-id\u003e\n\u003c/element-citation\u003e\n\u003c/ref\u003e"},{"refId":"j_jhp-2022-0008_ref_042","citeString":"Kozaci N, Avci M, Yuksel S, et al. Comparison of diagnostic accuracy of point-of-care ultrasonography and X-ray of bony injuries of the knee. Eur J Trauma Emerg Surg 2022; Feb 02. doi: 10.1007/s00068-022-01883-5. Epub ahead of print.","doi":"10.1007/s00068-022-01883-5","mixed-citation":"\u003cref id=\"j_jhp-2022-0008_ref_042\"\u003e\u003clabel\u003e42\u003c/label\u003e\n\u003cmixed-citation\u003eKozaci N, Avci M, Yuksel S, et al. Comparison of diagnostic accuracy of point-of-care ultrasonography and X-ray of bony injuries of the knee. \u003citalic\u003eEur J Trauma Emerg Surg\u003c/italic\u003e 2022; Feb 02. doi: \u003cpub-id pub-id-type=\"doi\"\u003e10.1007/s00068-022-01883-5\u003c/pub-id\u003e. Epub ahead of print.\u003c/mixed-citation\u003e\n\u003celement-citation publication-type=\"journal\" publication-format=\"print\"\u003e\n\u003cname\u003e\u003csurname\u003eKozaci\u003c/surname\u003e\u003cgiven-names\u003eN\u003c/given-names\u003e\u003c/name\u003e\n\u003cname\u003e\u003csurname\u003eAvci\u003c/surname\u003e\u003cgiven-names\u003eM\u003c/given-names\u003e\u003c/name\u003e\n\u003cname\u003e\u003csurname\u003eYuksel\u003c/surname\u003e\u003cgiven-names\u003eS\u003c/given-names\u003e\u003c/name\u003e\n\u003cetal/\u003e\n\u003carticle-title\u003eComparison of diagnostic accuracy of point-of-care ultrasonography and X-ray of bony injuries of the knee\u003c/article-title\u003e\n\u003csource\u003eEur J Trauma Emerg Surg\u003c/source\u003e\n\u003cyear\u003e2022\u003c/year\u003e\n\u003cmonth\u003eFeb\u003c/month\u003e\n\u003cday\u003e02\u003c/day\u003e\n\u003cpub-id pub-id-type=\"doi\"\u003e10.1007/s00068-022-01883-5\u003c/pub-id\u003e\n\u003ccomment\u003eEpub ahead of print.\u003c/comment\u003e\n\u003cdgpm:pub-id xmlns:dgpm=\"http://degruyter.com/resources/fetched-pubmed-id\" pub-id-type=\"pmid\"\u003e35107590\u003c/dgpm:pub-id\u003e\u003c/element-citation\u003e\n\u003c/ref\u003e"}],"pdfUrl":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/10.2478_jhp-2022-0008.pdf?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=cd616c1500bb7f69223fb1b32d8634e4044bf10865d7f5261a6d6ea8ab04565d","authorNotes":null,"publishMonth":"05","publishYear":"2022","receivedDate":null,"acceptedDate":null,"ePubDate":"2022-05-20T00:00:00.000+00:00","ePubDateText":"20 May 2022","pPubDate":null,"pPubDateText":null,"issueDate":"2022-01-01T00:00:00.000+00:00","coverDate":"2022-01-01T00:00:00.000+00:00","tableCount":null,"figureCount":null,"refCount":null,"articleCategories":"{\"subj-group\":{\"subject\":\"Clinical Practice\"}}","titleGroup":"{\"article-title\":\"Point of care ultrasonography in patients with haemophilia and acute haemarthrosis: a physiotherapist and sonographer inter-professional agreement pilot study\"}","fundingGroup":null,"abstractContent":[{"title":"Abstract","language":"English","content":"\u003cabstract\u003e\n\u003ctitle style='display:none'\u003eAbstract\u003c/title\u003e\n\u003csec\u003e\u003ctitle style='display:none'\u003eBackground\u003c/title\u003e\u003cp\u003eHaemophilia treatment centres (HTCs) around the world are increasingly adopting point-of-care ultrasonography (POCUS) for the assessment of acute haemarthrosis and to monitor joint health. POCUS is in large part administered by physiotherapists in most comprehensive care teams. Appropriate implementation of haemophilia-specific POCUS requires an educational foundation and training to ensure competency and optimal outcomes. Inter-professional agreement and evaluation of image quality are important measures of competency and acceptable use of POCUS.\u003c/p\u003e\u003c/sec\u003e\n\u003csec\u003e\u003ctitle style='display:none'\u003eAims\u003c/title\u003e\u003cp\u003eTo determine the level of agreement between physiotherapist and sonographer-performed POCUS scans and to compare the quality of the ultrasound images obtained by physiotherapists to those obtained by the sonographer.\u003c/p\u003e\u003c/sec\u003e\n\u003csec\u003e\u003ctitle style='display:none'\u003eMethods\u003c/title\u003e\u003cp\u003eThis single blind, prospective, pilot study recruited patients with haemophilia A and B who presented to clinic with a suspected acute haemarthrosis of the elbow, knee, or ankle and consented to participate. POCUS scans were performed by one trained physiotherapist and one sonographer in the haemophilia ambulatory clinic at patient presentation, one-week follow-up, and two-week follow-up. The physiotherapist participated in formal training consisting of 12 hours of online didactic modules and a two-day, 12-hour practical module with instructor-led hands-on training. For the primary objective, the outcome of interest was the binary decision on the presence or absence of blood within the joint. For the secondary objective, image quality was evaluated by the radiologist post hoc and rated as optimal, acceptable, or sub-optimal.\u003c/p\u003e\u003c/sec\u003e\n\u003csec\u003e\u003ctitle style='display:none'\u003eResults\u003c/title\u003e\u003cp\u003eThirteen participants with haemophilia consented to the study. The results indicated an excellent level of agreement (k=0.80) with an observed agreement of 91.7%, a specific positive agreement of 94.1%, and a specific negative agreement of 85.7% for the detection of blood within the joint space. The quality of the ultrasound images obtained by the physiotherapist were rated by the radiologist as optimal (84.6%) and acceptable (15.4%). None of the images were rated as sub-optimal.\u003c/p\u003e\u003c/sec\u003e\n\u003csec\u003e\u003ctitle style='display:none'\u003eConclusion\u003c/title\u003e\u003cp\u003eOptimal image quality and a high level of agreement between the physiotherapist and sonographer-performed POCUS for the assessment of acute hemarthrosis in people with haemophilia A and B was observed. These results suggest that, with a short formal training programme, physiotherapists can be proficient in the performance, acquisition, and interpretation of POCUS scans in patients with haemophilia.\u003c/p\u003e\u003c/sec\u003e\n\u003c/abstract\u003e"}],"figures":[{"label":null,"caption":"With appropriate training, physiotherapists can perform and interpret point-of-care ultrasound scans for the assessment of acute haemarthrosis to a level comparable to an experienced sonographer© Shutterstock","imageLink":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_011.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=7aa18200981337166cb758b459caba9ef30949a8c8bd6022b6f0324cfa0da3d4"},{"label":"Figure 1","caption":"Patient position and transducer orientation for posterior elbow joint recess","imageLink":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_001.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=a5a0f64f26611498b0566caf9a4fbc77d86eeb4cb5918469ff7140707047a942"},{"label":"Figure 2","caption":"Right elbow, posterior joint recess in long axis with overlying triceps tendon","imageLink":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_002.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=07bce862d05513dd6f6df5bc878b7fc9e543ea3d0350862e6edb66d2c40d0592"},{"label":"Figure 3","caption":"Patient position and transducer orientation for suprapatellar anterior joint recess","imageLink":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_003.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=b0f1ab3adf9fec52e6b8a92ce5f8a24c2fbcb61a5a7d0c77a466b9ee4cea188b"},{"label":"Figure 4","caption":"Right knee, suprapatellar anterior joint recess","imageLink":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_004.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=1928096bee31d30de254e4876ec307e25261669a9a9910db58501d9fd5fb4fcc"},{"label":"Figure 5","caption":null,"imageLink":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_005.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=9664b6de4f5d07bd8faa09f89e6372882f9a81f4f2309a4f376c18b63f63274d"},{"label":"Figure 6","caption":null,"imageLink":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_006.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=b81e1ecc08dbcabc2679f654939083eb5696953afc1453496c689839dae3bf09"},{"label":"Figure 7","caption":null,"imageLink":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_007.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=28e9423fbf92acc340ac71a2f3da65815e5c94d9bb997c7b409a04dd90cfccf8"},{"label":"Figure 8","caption":null,"imageLink":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_008.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=2ed00e107e965b0312fc89742177c5a5cf02676973e29e79194b7ec2b9439991"},{"label":"Figure 9","caption":"Patient position and transducer orientation for anterior tibiotalar joint recess","imageLink":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_009.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=0dc883e3698a24898eb99455e67b0c88b32fa7a9dcf0a61bd43c9cb1e83fad4d"},{"label":"Figure 10","caption":"Right tibiotalar joint, anterior joint recess in sagittal plane with overlying anterior tibialis tendon","imageLink":"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_010.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026X-Amz-Date=20220816T122539Z\u0026X-Amz-SignedHeaders=host\u0026X-Amz-Expires=18000\u0026X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026X-Amz-Signature=ec1204564bae5c2039d436add9cd7c63277fcc7839654e94e14a18b64b407d5a"}],"tableContent":{"Quality of ultrasound images":"\u003ctable frame=\"hsides\" rules=\"all\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\" valign=\"bottom\" rowspan=\"2\"/\u003e\n\u003cth align=\"center\" valign=\"bottom\" colspan=\"3\"\u003e\u003cbold\u003eQUALITY OF ULTRASOUND IMAGES\u003c/bold\u003e\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\" valign=\"bottom\"\u003e\u003cbold\u003eOPTIMAL\u003c/bold\u003e\u003c/th\u003e\n\u003cth align=\"left\" valign=\"bottom\"\u003e\u003cbold\u003eACCEPTABLE\u003c/bold\u003e\u003c/th\u003e\n\u003cth align=\"left\" valign=\"bottom\"\u003e\u003cbold\u003eSUB-OPTIMAL\u003c/bold\u003e\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003ePhysiotherapist\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e84.6%\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e15.4%\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e0%\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003eSonographer\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e88.9%\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e11.1%\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e0%\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e","Level of agreement on the presence or absence of blood within the joint":"\u003ctable frame=\"hsides\" rules=\"cols\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\" valign=\"top\"/\u003e\n\u003cth align=\"left\" valign=\"top\"\u003e\u003cbold\u003eKAPPA COEFFICIENT\u003c/bold\u003e\u003c/th\u003e\n\u003cth align=\"left\" valign=\"top\"\u003e\u003cbold\u003eAGREEMENT\u003c/bold\u003e\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\" valign=\"top\" colspan=\"3\"\u003e\u003chr/\u003e\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003eOverall (n= 36)\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003ek=0.80 (95% CI, 0.59–1.00) p=0.000\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003ePrevalence: 70.8%\u003cbreak/\u003eOA: 91.7%\u003cbreak/\u003eSPA: 94.1%\u003cbreak/\u003eSNA: 85.7%\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"},"tables":null,"articleContent":"\n\u003cdiv\u003e\n\u003csec id=\"j_jhp-2022-0008_s_001\"\u003e\u003ctitle/\u003e\n\u003cfigure id=\"j_jhp-2022-0008_fig_011\" position=\"float\" fig-type=\"figure\"\u003e\u003cfigCaption\u003e\u003cp\u003eWith appropriate training, physiotherapists can perform and interpret point-of-care ultrasound scans for the assessment of acute haemarthrosis to a level comparable to an experienced sonographer\u003c/p\u003e\u003cp\u003e© Shutterstock\u003c/p\u003e\u003c/figCaption\u003e\u003cimg xmlns:xlink=\"http://www.w3.org/1999/xlink\" xlink:href=\"graphic/j_jhp-2022-0008_fig_011.jpg\" src=\"https://sciendo-parsed-data-feed.s3.eu-central-1.amazonaws.com/6228ac980d198124537d1d3b/j_jhp-2022-0008_fig_011.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256\u0026amp;X-Amz-Date=20220816T122539Z\u0026amp;X-Amz-SignedHeaders=host\u0026amp;X-Amz-Expires=18000\u0026amp;X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20220816%2Feu-central-1%2Fs3%2Faws4_request\u0026amp;X-Amz-Signature=7aa18200981337166cb758b459caba9ef30949a8c8bd6022b6f0324cfa0da3d4\" class=\"mw-100\"\u003e\u003c/img\u003e\u003c/figure\u003e\n\u003cp\u003eHaemophilia is a haematological condition with orthopaedic manifestations. People with haemophilia (PwH) are prone to several complications. Haemarthrosis is the most frequent complication, accounting for 70–80% of all bleeding episodes \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_001\"\u003e1\u003c/a\u003e]\u003c/sup\u003e. Although any joint may be affected, hinge joints, particularly the ankles, knees and elbows, are the most commonly involved \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_001\"\u003e1\u003c/a\u003e]\u003c/sup\u003e. Blood within the joint space has detrimental effects on all joint structures and leads to the development of haemophilic arthropathy \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_002\"\u003e2\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_003\"\u003e3\u003c/a\u003e]\u003c/sup\u003e. A single haemarthrosis is capable of causing the same long-term arthropathy as seen in recurrent haemorrhages \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_004\"\u003e4\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_005\"\u003e5\u003c/a\u003e]\u003c/sup\u003e. Time between the initiation of joint bleeding symptoms and treatment with factor replacement therapy is crucial; however, some haemarthroses may present ambiguously. On initial presentation it may be difficult to assess if acute joint pain is due to a joint bleed or underlying arthropathy \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_006\"\u003e6\u003c/a\u003e]\u003c/sup\u003e. Recent evidence suggests that clinical examination alone is not sensitive enough to detect small amounts of blood within a joint \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_004\"\u003e4\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_006\"\u003e6\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_007\"\u003e7\u003c/a\u003e]\u003c/sup\u003e. Therefore, each bleeding event requires early and complete bleed assessment and management to ensure the best possible outcomes for PwH.\u003c/p\u003e\n\u003cp\u003eMagnetic resonance imaging (MRI) is the gold standard for the detection of haemarthrosis, however it is expensive, often inaccessible, and may require sedation of children to ensure that the images are not compromised by patient movement \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_008\"\u003e8\u003c/a\u003e]\u003c/sup\u003e. Computed tomography (CT) is another sensitive method; however, the benefits of CT may not outweigh the downside of ionising radiation \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_008\"\u003e8\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_009\"\u003e9\u003c/a\u003e]\u003c/sup\u003e. Ultrasound is time-efficient, nonionising, and relatively inexpensive \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_008\"\u003e8\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_010\"\u003e10\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_011\"\u003e11\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_012\"\u003e12\u003c/a\u003e]\u003c/sup\u003e. Ultrasound can detect complex fluid suggestive of blood within the joints of patients who are clinically asymptomatic, leading to the recommendation that ultrasound be used in combination with the clinical exam to inform treatment decisions following haemarthrosis \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_007\"\u003e7\u003c/a\u003e]\u003c/sup\u003e. However, clinical integration of ultrasound is limited by timely access to sonographers/radiologists with knowledge and experience in haemophilia. Further, treatment of haemarthrosis is time-sensitive, and same-day diagnostic imaging appointments are not always feasible. Point-of-care ultrasound (POCUS) is a modality that has the potential to address many of these challenges. POCUS is performed by a health care professional (HCP) at the bedside or in the ambulatory clinic, in combination with the clinical examination to identify the presence or absence of a specific clinical finding \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_013\"\u003e13\u003c/a\u003e]\u003c/sup\u003e. POCUS should be utilised when time saving for diagnosis or treatment is critical to patient care \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_013\"\u003e13\u003c/a\u003e]\u003c/sup\u003e. However, POCUS is a highly user-dependent modality, and there is a risk of misdiagnosis if it is used to aid clinical decision-making by inexperienced or untrained HCPs \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_014\"\u003e14\u003c/a\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eProficiency with the clinical examination and an understanding of the role of POCUS are important competencies for physiotherapists \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_015\"\u003e15\u003c/a\u003e]\u003c/sup\u003e. POCUS has been described within physiotherapy practice in orthopaedics or sport injuries to detect atrophy, tendon, ligament or muscle injury, in rheumatology to assist clinical decisions, and as a potential tool for physiotherapists working in critical care \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_016\"\u003e16\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_017\"\u003e17\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_018\"\u003e18\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_019\"\u003e19\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_020\"\u003e20\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_021\"\u003e21\u003c/a\u003e]\u003c/sup\u003e. It is important that physiotherapists who are using POCUS have confidence in their interpretation and findings, as this could impact the credibility of the profession, patient safety, support from regulatory colleges and licensing bodies, and collaboration with medical colleagues. A survey of orthopaedic surgeons and radiologists in the Netherlands reported no additional value of physiotherapist-performed POCUS in primary care \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_022\"\u003e22\u003c/a\u003e]\u003c/sup\u003e. This is a single study that assessed the subjective opinions of survey respondents; perceived disadvantages of physiotherapist-performed POCUS were false-positive or false-negative results, lack of experience, inadequate training, and the inability to correlate the reported findings on POCUS with other forms of imaging \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_022\"\u003e22\u003c/a\u003e]\u003c/sup\u003e. Even though this study reported a low survey response rate and a potential for response bias, the lack of trust radiologists and orthopaedic surgeons reported for physiotherapist knowledge and performance of POCUS in primary care should be addressed through future studies \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_022\"\u003e22\u003c/a\u003e]\u003c/sup\u003e. Rathi and colleagues investigated the inter-rater reliability of glenohumeral joint translation using POCUS \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_023\"\u003e23\u003c/a\u003e]\u003c/sup\u003e. Although high intra-rater reliability (physiotherapist: ICC 0.86–0.98, expert sonographer: 0.85–0.96) was found, it was moderate to good for posterior measurements (ICC 0.50–0.75) and poor to moderate for anterior measurements (ICC 0.31–0.53). These results suggest that to improve inter-rater reliability with an expert sonographer, the physiotherapist may benefit from additional or a different form of training \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_023\"\u003e23\u003c/a\u003e]\u003c/sup\u003e. Similar findings were reported by Thoomes-de Graaf and colleagues, who found a kappa coefficient of 0.36 between physiotherapists and radiologists on the use of diagnostic ultrasound in patients with shoulder pain across four diagnostic categories \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_024\"\u003e24\u003c/a\u003e]\u003c/sup\u003e. Although the level of agreement was low, this study reported that physiotherapists with more experience and training had a higher level of agreement with the radiologist than novice physiotherapists \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_024\"\u003e24\u003c/a\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTraining appears to be an important contributor to inter-rater reliability of physiotherapist-performed POCUS. Mayer and colleagues found excellent inter-rater reliability (ICC range 0.76–0.97) between a physiotherapist, physiotherapy students, and an expert physician sonographer following eight hours of structured formal training as a group and a one-hour private practical training session with the expert sonographer \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_025\"\u003e25\u003c/a\u003e]\u003c/sup\u003e. An inter-examiner agreement study of physiotherapists in the Netherlands found an acceptable level of overall agreement (61.7–93.6%) and specific positive agreement (43.9–91.4%) for detecting rotator cuff tears and other pathology \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_026\"\u003e26\u003c/a\u003e]\u003c/sup\u003e. The physiotherapists in this study had obtained certification on basic musculoskeletal ultrasound skills and completed a six-hour training programme specific to the study protocol with an expert in musculoskeletal sonography \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_026\"\u003e26\u003c/a\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003ePhysiotherapists in haemophilia treatment centres (HTCs) have extensive knowledge of anatomy, pathophysiology, and functional implications of a bleeding disorder on the musculoskeletal system. A global survey of HTCs found that the majority (70%) of POCUS scans were completed by physiotherapists \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_027\"\u003e27\u003c/a\u003e]\u003c/sup\u003e. In this study, an interdisciplinary panel of haematologists/oncologists, radiologists, and physiotherapists reported that physiotherapists are appropriate users for the acquisition and interpretation of POCUS scans in HTCs \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_027\"\u003e27\u003c/a\u003e]\u003c/sup\u003e. While several researchers have studied diagnostic ultrasound and the correlation with disease activity and haemophilic arthropathy, inter-professional agreement and an evaluation of image quality for physiotherapist-performed POCUS in PwH with acute haemarthrosis has not been investigated \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_028\"\u003e28\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_029\"\u003e29\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_030\"\u003e30\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_031\"\u003e31\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_032\"\u003e32\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_033\"\u003e33\u003c/a\u003e]\u003c/sup\u003e. Inter-professional agreement and evaluation of image quality are important measures of competency and acceptable use of POCUS. Image quality provides evidence to support the diagnosis of a bleed and decreases the chance of artifact incorrectly demonstrating pathology. Given the role of physiotherapists within HTCs in Canada, and the emergence of POCUS, the present pilot study aims to add novel research to this discussion.\u003c/p\u003e\n\u003cp\u003e\u003cbold\u003eObjectives:\u003c/bold\u003e\n\u003clist list-type=\"order\"\u003e\n\u003clist-item\u003e\u003cp\u003eTo determine the level of agreement between physiotherapist and sonographer-performed POCUS to assess for the presence or absence of blood in acute haemarthrosis in people with haemophilia A and B.\u003c/p\u003e\u003c/list-item\u003e\n\u003clist-item\u003e\u003cp\u003eTo compare the quality of the ultrasound images obtained by the physiotherapist to those obtained by the sonographer.\u003c/p\u003e\u003c/list-item\u003e\u003c/list\u003e\n\u003c/p\u003e\n\u003c/sec\u003e\n\u003csec id=\"j_jhp-2022-0008_s_002\"\u003e\u003cdiv\u003eMETHODS\u003c/div\u003e\n\u003csec id=\"j_jhp-2022-0008_s_002_s_001\"\u003e\u003cdiv\u003eStudy design\u003c/div\u003e\n\u003cp\u003eThis study was a single blind, prospective, pilot study.\u003c/p\u003e\n\u003c/sec\u003e\n\u003csec id=\"j_jhp-2022-0008_s_002_s_002\"\u003e\u003cdiv\u003eParticipants\u003c/div\u003e\n\u003cp\u003eA convenience sample of PwH with a suspected acute hemarthrosis of the elbow, knee, or ankle were recruited from a single HTC in Canada. The physiotherapist (KS) who performed the POCUS scan is a member of the Canadian Physiotherapists in Hemophilia Care, successfully completed the McMaster University Mohawk College POCUS Training Program for Acute Hemarthrosis and Synovitis, and has 17 years of experience in haemophilia care. The training programme includes 12 hours of online didactic modules and a two-day, 12-hour practical training module with instructor-led hands-on practice \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_034\"\u003e34\u003c/a\u003e]\u003c/sup\u003e. The didactic modules include summative assessments, and the practical component includes an assessment of competency using a simulated performance environment. The assessments were created to model the Sonography National Competency Profile developed by Sonography Canada and the Sonography Canada Clinical Skills Assessment Tool for this specific application of POCUS \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_034\"\u003e34\u003c/a\u003e]\u003c/sup\u003e. The sonographer (LF) who performed the ultrasound scan is a senior sonographer in the diagnostic imaging department at a large tertiary care hospital and has over 30 years of clinical experience in sonography. A single radiologist (NS) with 12 years of experience in ultrasound imaging and 10 years’ experience in paediatric imaging, provided oversight to the study and reviewed all POCUS scans and case report forms.\u003c/p\u003e\n\u003c/sec\u003e\n\u003csec id=\"j_jhp-2022-0008_s_002_s_003\"\u003e\u003cdiv\u003eStudy procedures\u003c/div\u003e\n\u003cp\u003eThe study procedure consisted of a POCUS performed by a physiotherapist and a sonographer. The POCUS scanning procedure is presented in \u003ca ref-type=\"app\" href=\"#j_jhp-2022-0008_app_001\"\u003eAppendix 1\u003c/a\u003e. The POCUS scans were performed in the haemophilia ambulatory clinic at patient presentation, one-week follow up, and two-week follow-up. The order of assessment was based on clinician availability. The sonographer was allowed to add additional images to the imaging protocol given their area of expertise, but the physiotherapist was instructed to acquire the images according to the scanning procedure. Ambiguous results were referred to the diagnostic imaging department for further formal investigation. Both the physiotherapist and the sonographer were blinded to each other's findings and to the results of previous scans. Methods of blinding included the use of a private clinic room and each clinician performing their assessment and documentation independently. Case report forms were placed in a sealed envelope. POCUS images were saved on the hard drive of the POCUS machine (GE Logiq) using an anonymous participant identification number.\u003c/p\u003e\n\u003c/sec\u003e\n\u003csec id=\"j_jhp-2022-0008_s_002_s_004\"\u003e\u003cdiv\u003eInclusion and exclusion criteria\u003c/div\u003e\n\u003cp\u003ePatients (age \u0026gt;1 year of age) with haemophilia A or B, with an acute haemarthrosis involving the elbow, knee, or ankle who presented to the clinic within five days of symptom onset were eligible to participate. Participants were excluded if there was an open wound over the scanning area, if an ultrasound scan of the haemarthrosis had already been completed, or if they were not able to read and understand English.\u003c/p\u003e\n\u003c/sec\u003e\n\u003csec id=\"j_jhp-2022-0008_s_002_s_005\"\u003e\u003cdiv\u003eOutcome assessment\u003c/div\u003e\n\u003cp\u003eOutcomes were assessed at presentation, one-week follow-up, and two-week follow up, resulting in a three-week study period. For the primary objective, the outcome of interest was the binary decision on the presence or absence of blood within the joint. As the technique and protocol in this study was specific to haemophilia, the criteria used to distinguish blood from effusion on ultrasound was blood presents as a complex fluid collection with mixed echogenicity and displaceable speckles on real time compression and effusion presents as simple anechoic fluid with the absence of echoes \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_035\"\u003e35\u003c/a\u003e]\u003c/sup\u003e. In the context of haemophilia with no symptoms suggestive of infection, complex effusions with mixed echogenicity can be assumed to represent haemarthrosis based on previous studies that have documented the accuracy of this approach using joint aspiration \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_035\"\u003e35\u003c/a\u003e]\u003c/sup\u003e. The physiotherapist completed the scanning protocol and interpreted the findings to make the binary assessment. Since interpreting ultrasound falls outside the scope of the sonographer, the sonographer provided an impression on the presence or absence of blood on the case report form. The radiologist read the sonographer images and provided a final diagnosis. The radiologist also reviewed the images of the physiotherapist performed ultrasound. To compare the level of agreement, the radiologist's final diagnosis was compared to the physiotherapist's interpretation. Both the physiotherapist and the sonographer recorded inconclusive ultrasound findings as absence of blood within the joint.\u003c/p\u003e\n\u003cp\u003eFor the secondary objective, criteria used to evaluate image quality were appropriate pre-sets, depth, field of view, focus, gains/time gain compensation, colour and/or power Doppler, with suitable landmarks and annotation. Image quality was evaluated by the radiologist post hoc and rated as optimal, acceptable, or sub-optimal. Optimal was defined as good image quality with optimal ultrasound settings and correct annotation/documentation. Acceptable was defined as good image quality, with one image setting that should have been better optimized or a minor error in annotation/documentation that did not impact the interpretation of the POCUS scan. Sub-optimal was defined as poor image quality with more than one image setting not sufficiently optimised or an error in annotation/documentation that impacted the radiologists’ interpretation of the POCUS scan.\u003c/p\u003e\n\u003c/sec\u003e\n\u003csec id=\"j_jhp-2022-0008_s_002_s_006\"\u003e\u003cdiv\u003eStatistical analysis\u003c/div\u003e\n\u003cp\u003eFor the primary objective, the prevalence of positive findings was calculated. The inter-rater agreement of the binary assessment of the presence and absence of blood within the joint was assessed with the kappa coefficient and 95% confidence intervals for the total sample and interpreted according to the categories by Landis and Koch \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_036\"\u003e36\u003c/a\u003e]\u003c/sup\u003e. As this is a pilot study, we did not set an a priori threshold for agreement. Observed agreement, specific positive agreement and specific negative agreement were also calculated to provide the results in a clinically relevant format \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_037\"\u003e37\u003c/a\u003e]\u003c/sup\u003e. For the secondary objective, the quality of the images was independently rated by the radiologist. Descriptive statistics including counts and percentages of optimal, acceptable, and sub-optimal for the physiotherapist and the sonographer performed POCUS scans were reported.\u003c/p\u003e\n\u003c/sec\u003e\n\u003csec id=\"j_jhp-2022-0008_s_002_s_007\"\u003e\u003cdiv\u003eEthics approval\u003c/div\u003e\n\u003cp\u003eThe proposed study received research ethics board approval from the Hamilton Integrated Research Ethics Board. All participants provided informed consent to participate in the study.\u003c/p\u003e\n\u003c/sec\u003e\n\u003c/sec\u003e\n\u003csec id=\"j_jhp-2022-0008_s_003\"\u003e\u003cdiv\u003eRESULTS\u003c/div\u003e\n\u003cp\u003eThirteen PwH met the inclusion criteria and were recruited into the study. Two of the POCUS scans involved elbows (15.4%), five (38.5%) ankles, and six (46.2%) knees. The median age of participants was nine years (interquartile range: five years).\u003c/p\u003e\n\u003csec id=\"j_jhp-2022-0008_s_003_s_001\"\u003e\u003cdiv\u003eLevel of agreement on the presence or absence of blood within the joint\u003c/div\u003e\n\u003cp\u003eAs presented in \u003ca ref-type=\"table\" href=\"#j_jhp-2022-0008_tab_001\"\u003eTable 1\u003c/a\u003e, the kappa coefficient was k=0.80 (95% CI, 0.59–1.00). The prevalence of positive findings was 70.8%, observed agreement was 91.7%, the specific positive agreement was 94.1%, and the specific negative agreement was 85.7%. The sonographer was absent and unable to complete three POCUS scans, these scans were excluded from the level of agreement analysis.\u003c/p\u003e\n\u003ctable-wrap id=\"j_jhp-2022-0008_tab_001\" position=\"float\"\u003e\u003clabel\u003eTable 1\u003c/label\u003e\u003ccaption\u003e\u003cp\u003eLevel of agreement on the presence or absence of blood within the joint\u003c/p\u003e\u003c/caption\u003e\n\u003ctable frame=\"hsides\" rules=\"cols\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\" valign=\"top\"/\u003e\n\u003cth align=\"left\" valign=\"top\"\u003e\u003cbold\u003eKAPPA COEFFICIENT\u003c/bold\u003e\u003c/th\u003e\n\u003cth align=\"left\" valign=\"top\"\u003e\u003cbold\u003eAGREEMENT\u003c/bold\u003e\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\" valign=\"top\" colspan=\"3\"\u003e\u003chr/\u003e\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003eOverall (n= 36)\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003ek=0.80 (95% CI, 0.59–1.00) p=0.000\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003ePrevalence: 70.8%\u003cbreak/\u003eOA: 91.7%\u003cbreak/\u003eSPA: 94.1%\u003cbreak/\u003eSNA: 85.7%\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable-wrap-foot\u003e\n\u003cfn-group\u003e\n\u003cfn\u003e\u003cp\u003ek: kappa coefficient; OA: observed agreement; SPA: specific positive agreement; SNA: specific negative agreement\u003c/p\u003e\u003c/fn\u003e\n\u003c/fn-group\u003e\n\u003c/table-wrap-foot\u003e\n\u003c/table-wrap\u003e\n\u003c/sec\u003e\n\u003csec id=\"j_jhp-2022-0008_s_003_s_002\"\u003e\u003cdiv\u003eQuality of ultrasound images\u003c/div\u003e\n\u003cp\u003ePost hoc analysis of the quality of the ultrasound images is shown in \u003ca ref-type=\"table\" href=\"#j_jhp-2022-0008_tab_002\"\u003eTable 2\u003c/a\u003e. The physiotherapist-performed POCUS scans demonstrated that 84.6% of the images were rated by the radiologist as optimal, 15.4% were rated as acceptable, and none were rated as sub-optimal. For the sonographer-performed POCUS scans, 88.9% of the images were rated as optimal, 11.1% were rated as acceptable, and none of the scans were rated as sub-optimal.\u003c/p\u003e\n\u003ctable-wrap id=\"j_jhp-2022-0008_tab_002\" position=\"float\"\u003e\u003clabel\u003eTable 2\u003c/label\u003e\u003ccaption\u003e\u003cp\u003eQuality of ultrasound images\u003c/p\u003e\u003c/caption\u003e\n\u003ctable frame=\"hsides\" rules=\"all\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\" valign=\"bottom\" rowspan=\"2\"/\u003e\n\u003cth align=\"center\" valign=\"bottom\" colspan=\"3\"\u003e\u003cbold\u003eQUALITY OF ULTRASOUND IMAGES\u003c/bold\u003e\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\" valign=\"bottom\"\u003e\u003cbold\u003eOPTIMAL\u003c/bold\u003e\u003c/th\u003e\n\u003cth align=\"left\" valign=\"bottom\"\u003e\u003cbold\u003eACCEPTABLE\u003c/bold\u003e\u003c/th\u003e\n\u003cth align=\"left\" valign=\"bottom\"\u003e\u003cbold\u003eSUB-OPTIMAL\u003c/bold\u003e\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003ePhysiotherapist\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e84.6%\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e15.4%\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e0%\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003eSonographer\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e88.9%\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e11.1%\u003c/td\u003e\n\u003ctd align=\"left\" valign=\"top\"\u003e0%\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable-wrap-foot\u003e\n\u003cfn-group\u003e\n\u003cfn\u003e\u003cp\u003eOptimal: good image quality with optimal ultrasound settings and correct annotation/documentation\u003c/p\u003e\u003c/fn\u003e\n\u003cfn\u003e\u003cp\u003eAcceptable: good image quality, one image setting should have been better optimised or a minor error in annotation/documentation that did not impact POCUS interpretation\u003c/p\u003e\u003c/fn\u003e\n\u003cfn\u003e\u003cp\u003eSub-optimal: poor image quality with more than one image setting not sufficiently optimised or an error in annotation/documentation that impacted POCUS interpretation\u003c/p\u003e\u003c/fn\u003e\n\u003c/fn-group\u003e\n\u003c/table-wrap-foot\u003e\n\u003c/table-wrap\u003e\n\u003c/sec\u003e\n\u003c/sec\u003e\n\u003csec id=\"j_jhp-2022-0008_s_004\"\u003e\u003cdiv\u003eDISCUSSION\u003c/div\u003e\n\u003cp\u003eAlthough pilot in design, this study adds to the emerging literature supporting the quality of physiotherapist-performed POCUS. The level of agreement between physiotherapist and sonographer is encouraging, suggesting that a trained physiotherapist is able to acquire and interpret POCUS scans of acute haemarthrosis in patients with haemophilia A and B at the same level of expertise as an experienced sonographer \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_036\"\u003e36\u003c/a\u003e]\u003c/sup\u003e. The specific positive agreement was greater than the specific negative agreement indicating better agreement when confirming the presence rather than the absence of blood within the joint. Clinically, these results indicate that if the physiotherapist performed and interpreted the POCUS scan as positive for presence of blood within the joint, the probability that the sonographer and radiologist would also confirm haemarthrosis is 94.1%. Encouraging results were also found for the absence of blood within the joint with the probability of absence of blood at 85.7%. While agreement was less for the absence of blood, the results were still high. Clinically, this supports physiotherapist consultation with radiology to determine whether further imaging is required if the POCUS scan indicates a lack of blood in the joint but other indicators such as patient symptomatology, mechanism of injury, inhibitor status, trough level, and underlying joint health, are all highly suggestive of haemarthrosis. The quality of the images obtained by the physiotherapist were optimal and comparable to the sonographer. This indicates that the trained physiotherapist was able to produce images that support the diagnosis on the presence or absence of a joint bleed with a low likelihood of imaging artifact incorrectly demonstrating or missing pathology.\u003c/p\u003e\n\u003cp\u003eIn clinical practice, POCUS images are seldom stored for future review or comparison \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_038\"\u003e38\u003c/a\u003e]\u003c/sup\u003e. This process has been questioned as it limits the possibility of performing quality assurance audits and does not acknowledge the importance of reviewing serial scans to assess for the evolution/resolution of pathology \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_038\"\u003e38\u003c/a\u003e]\u003c/sup\u003e. To be consistent with this process and to maintain the independence of POCUS scans, the current study blinded the physiotherapist and the sonographer to the images and findings from previous scans. However, given the evolution of blood on ultrasound, the potential for underlying joint arthropathy in PwH, and the role of normal physiologic fluid in synovial joints, it may be important for the POCUS operator to have access to previous POCUS scans. Being able to access previous images can facilitate analysis of the clinical evolution of pathology and physiologic fluid, which may have implications on the level of agreement between the trained physiotherapist and sonographer as there may be variations in agreement at different stages of recovery. Also, recording previous images may decrease health care costs. If the POCUS scans are done with similar standards as diagnostic imaging, accessing stored images may avoid the need for repeat scans if clinical questions arise that may require consultation with radiology. These considerations may have implications for education and clinical practice and will be important areas for future study.\u003c/p\u003e\n\u003cp\u003eThe current study had a number of strengths. The physiotherapist was trained to a set standard for this specific application of POCUS by an accredited academic institution. Both the physiotherapist and the sonographer were blinded and were provided with a standardised scanning protocol, with the order of assessment randomised based on clinician availability. Both the physiotherapist and the sonographer used the same ultrasound machine and after each POCUS scan the machine was returned to the main screen to maintain blinding and the independence of scans. All 13 participants recruited into the study attended all study visits. Lastly, the study procedures were consistent with the traditional pathway in diagnostic imaging. The study was designed in this manner to ensure that the same quality and standard of care was provided in the clinic setting.\u003c/p\u003e\n\u003cp\u003eAlthough this is a pilot study, its main limitations are the small sample size and inclusion of a single physiotherapist and sonographer, both of which may impact generalisability. While the results suggests that a short training programme provided the physiotherapist with an appropriate level of education and training in the performance, acquisition, and interpretation of POCUS scans in PwH, this needs to be replicated with physiotherapists and sonographers with varying levels of training and experience. It would be interesting to compare the competencies of sonographers with no musculoskeletal experience to physiotherapists who have completed POCUS training specific to the musculoskeletal system. Future inter-professional agreement studies should also consider including other members of the haemophilia comprehensive care team, such as physicians/haematologists and nurses, who may be using POCUS in clinical practice. In addition, with the decreasing annualised bleeding rates in PwH \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_039\"\u003e39\u003c/a\u003e]\u003c/sup\u003e, a multi-centre trial would be needed to obtain a sufficient number of suspected bleeding episodes for a definitive study.\u003c/p\u003e\n\u003cp\u003eThis study focused on hinge joints of the knee, ankle, and elbow, which account for the majority of haemarthrosis in PwH and are easily accessible with relatively simple POCUS scanning protocols. Future research would need to look at the inter-professional agreement and image quality for more complex joints, such as the ball-and-socket joints (i.e. shoulder and hip). Although haemarthrosis could occur in patients with other musculoskeletal injuries, these results should only be applied to the assessment of haemarthrosis in patients with haemophilia \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_040\"\u003e40\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_041\"\u003e41\u003c/a\u003e,\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_042\"\u003e42\u003c/a\u003e]\u003c/sup\u003e. The protocol and training received by the physiotherapist in this study was specific to haemophilia and it is important to remember that one of the downsides of POCUS occurs when users extrapolate beyond their protocol and training \u003csup\u003e[\u003ca ref-type=\"bibr\" href=\"#j_jhp-2022-0008_ref_013\"\u003e13\u003c/a\u003e]\u003c/sup\u003e. Generalising the findings of this study to patients with other conditions should therefore be done with caution. However, this study does demonstrate that within a relatively short period of formal training, including both didactic and practical curricula, physiotherapists can become proficient in POCUS. Given their background knowledge in anatomy and physiology, this study lends support for physiotherapists to be trained to use POCUS with different patient populations and conditions.\u003c/p\u003e\n\u003c/sec\u003e\n\u003csec id=\"j_jhp-2022-0008_s_005\"\u003e\u003cdiv\u003eCONCLUSION\u003c/div\u003e\n\u003cp\u003eOptimal image quality and an excellent level of agreement between the physiotherapist and sonographer-performed POCUS for the assessment of acute haemarthrosis in people with haemophilia A and B was observed. This pilot study found that a physiotherapist who received appropriate training in the McMaster University Mohawk College Training Program can perform and interpret POCUS scans for the assessment of acute haemarthrosis to a level that is comparable to an experienced sonographer. Further investigation is warranted.\u003c/p\u003e\n\u003c/sec\u003e\n\u003c/div\u003e","keywords":[{"title":"Keywords","language":null,"keywords":["Haemophilia","Point of care systems","Ultrasonography","Physical therapists","Physical therapy modalities","Physical therapy specialty","Education"]}],"recentIssues":{"10.2478/jhp-2022-0006":"\u003carticle-title\u003eDiscrete choice experiments: An overview of experience to date in haemophilia\u003c/article-title\u003e","10.2478/jhp-2022-0005":"\u003carticle-title\u003eOsseous bilateral pseudotumour of the thumb in severe haemophilia A – A case report\u003c/article-title\u003e","10.2478/jhp-2022-0008":"\u003carticle-title\u003ePoint of care ultrasonography in patients with haemophilia and acute haemarthrosis: a physiotherapist and sonographer inter-professional agreement pilot study\u003c/article-title\u003e","10.2478/jhp-2022-0007":"\u003carticle-title\u003eDevelopment of decision-making considerations to support equitable patient selection in paediatric haemophilia trials\u003c/article-title\u003e","10.2478/jhp-2022-0002":"\u003carticle-title\u003eKey challenges for patient registries – A report from the 1\u003csup\u003est\u003c/sup\u003e workshop of the EHC Think Tank Workstream on Registries\u003c/article-title\u003e","10.2478/jhp-2022-0001":"\u003carticle-title\u003eNew challenges for an expanding generation of older persons with haemophilia\u003c/article-title\u003e","10.2478/jhp-2022-0004":"\u003carticle-title\u003ePatient agency: key questions and challenges – A report from the 1st workshop of the EHC Think Tank Workstream on Patient Agency\u003c/article-title\u003e","10.2478/jhp-2022-0003":"\u003carticle-title\u003eKey challenges for hub and spoke models of care – A report from the 1st workshop of the EHC Think Tank on Hub and Spoke Treatment Models\u003c/article-title\u003e","10.2478/jhp-2022-0011":"\u003carticle-title\u003e“I didn’t know women could have haemophilia”: A qualitative case 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","Download Cover":" Download Cover","Articles":" Articles ","Details, Metrics \u0026 Owners":" Details, Metrics \u0026 Owners ","Aims \u0026 Scope":" Aims \u0026 Scope ","Editorial Board":" Editorial Board ","Abstracting \u0026 Indexing":" Abstracting \u0026 Indexing ","Issues":" Issues ","Submit":" Submit ","Journal Metrics":" Journal Metrics ","Impact Factor":" Impact Factor ","Five Year Impact Factor":" Five Year Impact Factor ","Cite Score":" Cite Score","Journal Owners":" Journal Owners ","Editor-in-Chief":" Editor-in-Chief ","news":"News","profile":"Profile","signOut":"Sign Out","login":"Login","createAccount":"Create Account","about":"About","aboutUs":"About","cart":"Cart","standard":"Standard","classic":"Classic","premier":"Premier","hostingPlatform":"Hosting platform","onlineSubmissionSystem":"Online submission system","typesetting":"Typesetting and proofreading","XMLpublication":"Fulltext XML publication","copyediting":"Copyediting (heavy edit)","wideElectronicDistribution":"Wide electronic distribution","contentAndJournalIndexing":"Content and journal indexing","marketingExtraPackage":"Marketing Extra Package","consulting":"Consulting","accountManagement":"Account management","bookLayout":"Book layout, cover design","ePubVersion":"ePub version","printOnDemand":"Print on demand and delivery","contentAndBookIndexing":"Content and book indexing","journals.first":"Sciendo publishes academic journals that belong to universities, research institutes, academies of sciences, learned societies and other organizations. We can publish them both in the Open Access and in traditional ( paid access) models. We currently publish journals in the English, German, French, Spanish, Italian and Polish languages.","journals.second":"We have a special offer for universities and other organizations to publish their journals, books and other publications. \u003c1\u003eSee more here.\u003c/1\u003e","journals.third":" Please download the \u003c1\u003ebrochure\u003c/1\u003e for more information. Please contact our representative for your territory, to meet and discuss the terms.","journals.fourth":"The content is available here \u003c1\u003ehttps://content.sciendo.com/\u003c/1\u003e","journals.fifth":"\u003c0\u003eIMPACT FACTORS 2019\u003c/0\u003e","books.first":"Sciendo can meet all publishing needs for authors of academic and professional books in the English language. We publish monographs, textbooks, edited volumes, and other book types. 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And — if they believe the book can sell well — they would like to receive a significant part of the sales revenues.","selfPublishingContent.second":"If you supply a ready-made publishable eBook file, we can host, distribute, sell and promote your book free of any charge. \u003c1\u003eYou will receive 70% of net revenues from the book sales.\u003c/1\u003e In addition, you have the option of choosing some of our paid services, including eBook formatting.","selfPublishingContent.third":"To see the complete list of publishing services and solutions that Sciendo offers to Self-publishing authors, as well as the relevant fees, \u003c1\u003eregister here\u003c/1\u003e","selfPublishingContent.fourth":"To learn more about these services, please contact Magdalena Cal, Customer Service Manager at \u003c1\u003emagdalena.cal@sciendo.com\u003c/1\u003e","selfPublishingContent.fifth":"You can also \u003c1\u003edownload the Self-Publishing brochure\u003c/1\u003e for more information.","fullPublishingContent.first":"Sciendo publishes books from universities, research institutes, academies of sciences, learned societies and other organizations. 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