There is a wealth of evidence to demonstrate the benefits of sport and exercise for general health as well as specific benefits for people with haemophilia. As a result, it is widely accepted that regular participation in physical activity should form an important part of the management of haemophilia. Indeed, people with haemophilia who exercise regularly exhibit fewer bleeds, and can have similar strength and function to their peers who do not have haemophilia. However, having established that sport and exercise are beneficial, the literature is conflicting as to which activities are optimal.
Management of haemophilia has changed over the years. We are now in an era of modern clotting factor replacement therapy, comprehensive care programs and clotting factor prophylaxis, which enables PWH to experience a greater sense of responsibility and independence with respect to their own health. The availability of clotting factor for the management of bleeding directly correlates with this change in attitude towards participation in exercise and activities, which was previously limited for PWH due to concerns regarding induction of bleeding.
Factors to consider when selecting a sport or exercise
There are various classification lists in existence that recommend which sports are best for PWH to participate in. These may be based on:
- The probability of contact or collision
- Incidence of injuries (high, medium or low risk)
- The frequency of recorded injuries in this sport.
More complex parameters are now also being proposed to classify sports including:
- Biomechanical aspects
- Level of difficulty
- Risk of injury.
Guidelines and risk assessment tools
There are various guidelines and risk assessment tools that have been published over the last 30 years. Examples include:
- The American Paediatric Society (APS) list
- “Playing It Safe” (US National Haemophilia Foundation)
- “Go for it” (a book by Jones, Buzzard and Heijnen 1998)
- “Physical activity and sport for haemophilic patients” (Heijnen 1989)
- “Haemophilia and Sports” (Gilbert et al 1984 for National Haemophilia Foundation and American Red Cross)
- German risk assessor (Seuser, 2007)
- BRUCE calculator (Herbert, Broderick and Latimer 2012)
A myriad of others also exist although NONE are exactly the same or agree in totality.
The list of sports outlined by the SportsZone tool is based on one of the most widely used classifications to prescribe sport – the American Paediatric Society (APS) list. This list is based on the notion that the majority of sports injuries requiring medical attention are collision injuries. Thus, sports are classified according to the probability to collide or contact, and divided into three groups: contact, minimal contact and non-contact.
All guidelines have limitations
It should be noted that there are limitations to all the guidelines. In most cases lists are generated on theoretical risk, and the experience and opinions of haemophilia treaters who may have limited knowledge of the specific complexities and demands of the sport. Information may also be extrapolated from national statistics which may not allow for issues specific to haemophilia, for example, some sports may be classified as high risk due to high frequency of injury, despite the injuries being mild, whereas others may be classified as medium risk, where injuries are rare, but if sustained may be catastrophic (e.g. head injuries).
It is also important to remember that direct contact may not only be the cause of bleeds in haemophilia; muscle strains and overloaded joints can occur due to many non-contact sports, such as weightlifting.
Selecting a sport or exercise should be individualised for each PWH
There are significant differences between countries, and even within countries, with regard to the type of sports played, and their guidelines. The accompanying SportsZone tool has been modified to include sports commonly played in Australia.
How sports are played will also influence the likelihood of injury, e.g. competitive sport is more likely to give rise to injury as opposed to training or a backyard game of cricket.
Age should also be a consideration when selecting a sport. Progression of a sport from non-contact to contact as the child ages may result in unrealistic expectations or increase chances of injury if continued. The repetitive motion in some sports may also cause muscle imbalance, especially on the developing skeleton, e.g. weight-lifting is contraindicated in those who are not skeletally mature. During growth spurts adolescents are particularly vulnerable to injury due to imbalance between strength and flexibility.
The majority of the literature now advises that the decision making process regarding which sport or exercise is appropriate is individual to each person and should be done collaboratively, taking into account:
– Clinical status
– PWH interests and desires
– PWH abilities, capabilities and existing joint damage.
Decreasing the risk of injuries
The following may help decrease the risk of injury or its potential adverse sequelae:
- Having a good understanding of the risks involved and the potential consequences of participating in a specific sport (e.g. potential for life-threatening injury such as intracranial bleed, time off work/school/university, need for rehabilitation)
- Appropriate timing of prophylaxis i.e. immediately prior to playing the sport, not the night before!
- Appropriate individualised selection of the sport or exercise according to the PWH’s size and physical characteristics (i.e. matched for size and development, not age)
- Appropriate rehabilitation of previous injury or existing pathology
- Appropriate training and technique
- Available management plan for PWH, coach, parent, school, etc.
- Administering immediate clotting factor treatment and RICE in the case of injury and undergoing a full rehabilitation program prior to return to the sport/exercise
- Gaining the necessary skills required for the sport or exercise including regular training, guidance from an expert trainer, and knowledge of the rules
- Wearing the correct gear (e.g. appropriate clothing and footwear) and use of protective gear.
- Boys will be Boys – by Brendan Egan (2005): a guide to sports participation for PWH and other bleeding disorders, available from all local haemophilia centres in Australia/New Zealand
- Fitness and Exercise Guide for Young Adults with Haemophilia – by Ian d’Young (2012): available as a booklet from all local haemophilia centres in Australia/New Zealand
- World Federation of Haemophilia: Go For It http://www.wfh.org/en/resources/publications-list
- Fit for Life – Fitness Levels of Young Haemophiliacs Today – by Anatol Kurme and Axel Seuser (2004): a guide to fitness, games, sport and dance for PWH
- Playing it Safe: Bleeding Disorders, Sports and Exercise – US National Haemophilia Foundation
- Your local or specialist physiotherapist!
This information is not intended as medical advice. Before commencing any sporting activity, please consult your Haemophilia Treatment Centre.