Activities and Levels of Bleeding Risk They May Carry Ranked by Physical Therapists

Repetitive movements, fitness level, and prolonged and competitive physical activity are among the factors that raise bleeding risks for people with hemophilia taking part in such activities, a study based on a survey of physical therapists in the U.S. reports.

Duration of training and safety equipment were seen as modifiable factors, and specific activities — from football and archery to yoga, walking and Frisbee — were ranked in terms of bleeding and injury risks.

The study, “Ranges and drivers of risk associated with sports and recreational activities in people with haemophilia: results of the Activity‐Intensity‐Risk Consensus Survey of US physical therapists,” appeared in the journal Haemophilia.

Concerns about causing bleeds, particularly in the muscles or joints, is constant for people with bleeding disorders who participate in physical activity.

Improvements in factor replacement therapy and accumulating evidence on the benefits of exercise have led to physical activity being recommended for this patient population to improve fitness and promote normal neuromuscular and bone development.

Patients with hemophilia are generally advised to consider the risk of injury before starting an exercise program or activity and to consult with experienced physical therapists (PTs). However, evidence is scarce and helpful materials are lacking on the risks of specific activities, and not all treatment centers have adequate experience in this area.

The Activity‐Intensity‐Risk (AIR) study was designed to address these gaps and to define modifiable drivers of risk. A survey as to the risk of injury associated with 101 sports and recreational activities was administered to peer‐nominated PTs in the U.S. hemophilia treatment center network. The therapists assigned risk scores ranging from minimum (one) to maximum (five), and indicated bleeding risks in six joints and three categories of injury — bruising, muscle bleeding, and head injury.

A consensus meeting then categorized identified risk factors as inherent or modifiable, and activity‐driven or patient‐driven. A multi‐specialist group — including physicians, nurses, nurse practitioners, PTs and social workers — also evaluated how the findings may be used in communicating with patients and their families.

A total of 17 peer-nominated physical therapists participated in the study; overall, these people had a median experience of 24 years as a PT and of 16 years at a hemophilia treatment center. Fifteen PTs reported treating both adults and children.

Eight therapists participated in the consensus meeting. Fifteen drivers of bleeding risk were  identified: progression from seasonal to year‐round participation, overuse/overtraining, improper body mechanics, repetitive motion, prolonged position, competitive activities, tournament effect (or duration), fitness level, field or surface condition, impact with other players, impact with surface/ball/equipment, impact due to a fall or accident, use of safety equipment, risky tricks or stunts, and hemophilia‐specific risk for injury.

Inherent risks included impact activities, such as those involving an impact with a ball or exercise equipment, and field or surface conditions. Modifiable risks included whether safety equipment was used, if tricks or stunts were involved, body mechanics, and whether overuse or overtraining took place.

Drivers most frequently identified as activity‐driven included body mechanics and training and repetitive motion. In turn, drivers most often indicated as patient-driven risks were overuse or overtraining, year-round activity, and use of safety equipment.

Swimming, even if year-round competitive, was associated with low-risk scores. Other low-risk activities  were fishing, Frisbee, Frisbee golf, gardening, snorkeling, stationary bicycling, tai chi fitness classes and martial arts, walking, and water aerobics. In contrast, boxing, mixed martial arts, rodeo, rugby, and tackle football had consistent high risk scores.

Different positions and participation levels correlated with variable risks within specific sports. Examples included baseball pitcher and catcher positions, which were associated with greater median minimum and maximum risk ratings compared with other baseball positions, and football participation levels — flag football is less risky than tackle football, especially for head injury.

In baseball, risks for shoulder and elbow bleeding were identified by most PTs participants for all positions, but risks for wrist bleeding was highest for pitchers (76%), and of knee bleeding was highest for catchers (100% of respondents). In turn, soccer goalies had greater reports of risks in the shoulders, elbows and wrists, but lower in the knees and ankles than other soccer positions.

Most activities were associated with bleeding risks in multiple joints, although some activities were highly specific for certain joints. One example is archery, with specific risks for the shoulders (86%), elbows (93%) and wrists (64%). Risk for bruising ranged from 0% (yoga) to 100% (wrestling), while head injury risks ranged from 0% (bowling) to 100% (skateboarding). Almost all activities were identified as having a specific risk for muscle bleeding by most participants, ranging from 33% (walking) to 100% (bicycling).

“This report of the AIR study provides a comprehensive resource that individuals may use to inform and facilitate discussion regarding selection of appropriate activities and optimal risk management strategies,” the scientists wrote.