Physical therapists (PTs) at hemophilia treatment centers (HTCs) often consult with hemophilia patients about engaging in new physical activities like exercise, team/individual sports, and other recreational endeavors. PT/patient discussions will, in many cases, cover the appropriateness of the proposed activity, potential risks and ways in which some these risks could be mitigated. While resources exist to help guide a general discussion of risk, there remains the need for a comprehensive tool that can foster more informed and dynamic activity/risk management strategy discussions between providers, patients and their families.
The Activity‐Intensity‐Risk (AIR) study, published in the peer reviewed journal Haemophilia, was therefore designed to improve understanding of activity‐specific risks for people with hemophilia. AIR took shape through the hard work of 17 HTC PTs, each of whom participated in a survey of 101 physical activities. The average experience of the participants was 22.4 years and 16.9 years at an HTC.
For each activity the PTs provided minimum/maximum risk scores. They also indicated specific bleeding risks in six joints and three injury types, including bruising, head injury and muscle bleeding. Once the survey results were tabulated, a full-day consensus meeting was conducted to explore the free text comments and identify “risk drivers” for each activity. The drivers were then categorized as inherent or modifiable. A multi-specialist focus group consisting of PTs, registered nurses, nurse practitioners, physicians, social workers then convened to discuss ways in which this data could be utilized during conversations of risk with patients and families.
The activities most consistently rated as low risk were fishing, Frisbee®, Frisbee® golf, gardening, snorkeling, stationary bicycling, tai chi fitness classes and martial arts, walking and water aerobics. Those activities most consistently rated high risk were boxing, mixed martial arts, rodeo, rugby and tackle football. Most participants cited at least one specific risk for each activity. One example is archery, which saw a high percentage of PTs rate as a risk for joint bleeding, specifically in the shoulders (86%), elbows (93%) and wrists (64%). In terms of risk for bruising, wrestling rated highest (100%), while yoga was rated lowest (0%). For team sports, risk ratings were broken down by position. In some instances, this led to varying risk ratings depending on the specific joint and the position. Two team sports, baseball and soccer provided valuable illustrations.
While in baseball, specific risks for shoulder and elbow bleeding were identified by most PTs for all three positions (pitcher, catcher and “other”; range, 82%‐100%), indications of risk for wrist bleeding specifically were much higher for pitchers (76%) compared with catchers (47%) and “others” (40%), and risk of knee bleeding was substantially higher for catchers (100%) compared with pitchers (35%) and “others” (53%). When comparing soccer goalie to soccer “other” positions high numbers of PTs reported specific risks in the knees (88% vs 100%) and ankles (94% vs 100%); however, soccer goalie was associated with substantially greater reports of specific risks in the shoulders (63% vs 6%), elbows (56% vs 6%) and wrists (63% vs 0%).
The free text comments and the subsequent meeting ultimately yielded 15 agreed upon risk drivers including overuse/overtraining, repetitive motion, prolonged position, year‐round activity, competitive vs recreational, tournament effect (or duration), body mechanics and training, 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 injury risk. The drivers were then identified as either inherent or modifiable, and activity driven or patient driven risks. Drivers most frequently recognized as inherent risks included impact with surface/ball/equipment and field or surface condition, while those often seen as modifiable for risk included body mechanics, training and overuse/overtraining. Drivers most commonly indicated as activity‐driven included body mechanics and training and repetitive motion, and drivers most often indicated as patient‐driven risks included overuse/overtraining, year‐round activity and use of safety equipment.
“Patient‐driven modifiable risk drivers may offer the greatest opportunities for modifications to be made to decrease risk; for example, preventing overuse/overtraining in the context of tennis or snowboarding, and improving body mechanics and training in the context of cross‐country running or bowling may be important strategies for minimizing risk. Conversely, inherent activity‐driven risk drivers may offer few opportunities to decrease risk; for example, little can be done to prevent impact with a surface, ball, or equipment in the context of basketball or ice hockey, or to lessen the impact of field or surface condition in the context of beach volleyball or mountain biking,” explained the authors.
Limitations cited by the authors include the small number of PT participants, potential for recruitment bias and the reliance on expert opinion rather than objective patient data. They go on to explain that a patient should always be evaluated by medical staff to help inform any risk management strategy.
“Future efforts to improve our understanding of specific risks associated with physical activities may include collection of detailed bleeding data in relation to intensity and specific action/movement associated with the bleed, the treatment regimen prescribed and administered, and the patient's underlying fitness and joint status. This may be accomplished through a bleeding disorder activity registry or prospective study.
Hernandez G, Baumann K, Knight H, et al. 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. Haemophilia. 2018 Nov 20; 24(57): 5-26.
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