Bleeding disorders, sports and exercise

BLEEDING DISORDERS, 

SPORTS AND EXERCISE

Playing It Safe

N

AT I O N A L

H

E M O P H I L I A

F

O U N D AT I O N

for all bleeding and clotting disorders

Table of Contents

Author’s Note .........................................................................................2

Should People with Bleeding Disorders Participate 

in Sports and Exercise .........................................................................2

For Parents of Infants, Toddlers and Preschoolers ....................................4

For Parents of School-Age Children .........................................................5

For Teens and Adults...............................................................................7

For People with Mild or Moderate Bleeding Disorders.............................8

Before You Start ......................................................................................8

Conditioning ...........................................................................................9

Stretching .............................................................................................10

Strengthening.......................................................................................10

Aerobic Training....................................................................................12

Measuring Your Effort...........................................................................12

Sports Safety and Instruction ................................................................15

Choosing a Sport, What To Think About...............................................16

Safe or Dangerous ................................................................................17

Sports Ratings by Activity......................................................................18

Continuing in Sports and Exercise 

After Bleeding Episodes .............................................................33

Summing It Up: Prepare Yourself, Choose Wisely…and Have Fun! .......33

Appendix 1 General Stretching Program...............................................35

Appendix 2 Strength Training Recommendations ...............................40

Appendix 3 Cardiovascular Activity Recommendations ..........42

Additional Resources........................................................44

The National Hemophilia Foundation (NHF) is

dedicated to finding better treatments and

cures for bleeding and clotting disorders and to

preventing the complications of these disorders

through education, advocacy and research. 

Written by

Alice Anderson, PT, MS, PCS

Angela Forsyth, MS, PT

Based on an original publication by

Marvin S. Gilbert, MD

Managing Editor

Neil Frick, MS

Acknowledgements

The National Hemophilia Foundation would like to thank

Marion A. Koerper, MD, the Publications Working Group and all

those individuals who reviewed drafts of this publication. 

The information contained in this publication is provided for your

general information only. NHF does not give medical advice or engage in

the practice of medicine. NHF under no circumstances recommends

particular treatment for specific individuals and in all cases

recommends that you consult your physician or local treatment

center before pursuing any course of treatment. 

This publication was supported by Cooperative Agreement

Number 214593 from the Centers for Disease Control and

Prevention (CDC). Its contents are solely the

responsibility of the authors and do not necessarily

represent the official views of the CDC.

© 2005 National Hemophilia Foundation. Material in this publication

may not be reproduced without written permission from the National

Hemophilia Foundation.

Bleeding Disorders, 

Sports and Exercise

PLAYING IT SAFE

Of course, safety is important;

activities must be age appropriate

and properly supervised. Advances in

prophylaxis have made it easier and

safer for people with bleeding

disorders to take part in a variety of

activities, but bleeding due to injury

is still a possibility. You should

consider the timing of treatment in

relation to physical activity. Ideally, activity should

take place soon after treatment, when your factor level is at a peak.

Whether or not a person is on prophylaxis, it is essential that any injury

be evaluated and treated by the HTC.

For adults with bleeding disorders, decisions about

physical activity still require preparation and

education. When children with bleeding

disorders want to exercise or take part in a

sport, particularly in competitive or team

activities, their parents, school personnel,

coaches, healthcare providers, and even

the children themselves, may have

concerns. 

In this booklet, you’ll find information to ease your

concerns and help you make an informed decision.

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Authors’ Note 

People with bleeding disorders vary widely in how they respond to taking

part in sports and exercise. While the recommendations in this booklet

regarding specific activities may generally apply to those with bleeding

disorders, they may be inappropriate for some people. Consult with your

Hemophilia Treatment Center (HTC) prior to engaging in any sport or

exercise regimen. 

Should People with Bleeding Disorders

Participate in Sports and Exercise? 

The answer is a definite “Yes!” You can choose among a

wide range of physical activities, from traditional sports like T-

ball and tennis to forms of exercise like walking and yoga. Sports

and exercise are connected, as well; activities often thought of as

exercise, like stretching and aerobics, can be part of

conditioning for a sport. No matter what your choice, being

active is good for everyone. It contributes to physical fitness, and

it can have a positive effect on psychological and emotional well-being.

Regular physical activity has other specific benefits, too: 

It builds 

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healthy bones, muscles, joints

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lean body mass

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self-esteem and self-confidence

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teamwork

It increases

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“good” cholesterol (HDL)

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academic performance

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energy level

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It decreases

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weight

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feelings of depression and anxiety

It decreases the risk of developing

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spontaneous joint bleeds

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high blood pressure

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heart disease

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stroke

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diabetes

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colon cancer

  

                                           

The age for starting different activities, such as riding a bicycle, will

vary from child to child, based on their bleeding severity, emotional

maturity, and skill level. Infants can enjoy swimming and water play, and

some children may begin skating, martial arts, or T-ball at age four.

For Parents of School-Age Children

Sports play a large part in the life of school-age children, so it’s

important to give your child the chance to participate. Studies have

shown that children with strong musculoskeletal systems have fewer

spontaneous bleeding episodes.* And the best way to develop strong

muscles is through regular physical exercise that allows children to build

strength, endurance, and agility.

Physical activity also helps school-age children develop socially and

emotionally. In competitive sports, they learn teamwork and how to win

and lose. Being recognized for their accomplishments also increases your

child’s self-esteem—especially when the recognition comes from friends

and classmates. Their emotional state can even affect bleeding; as children

become more confident and independent, they often show marked clinical

improvement, with fewer spontaneous bleeding episodes.

Despite these benefits, parents and school personnel often have

concerns about sports participation. You might worry that your child will

fail at an athletic activity, because bleeding episodes keep them from

continuing or because they can’t physically keep up with their

peers. What can you do to lessen the likelihood of

failure? The answer is simple: encourage your child to

choose a sport that promises a relatively good chance

of success. Allowing your child to practice assists in

preparation and helps them develop the skills and

strength they will need. Your child’s risk of failure should

then be no greater than that of any child who participates in a

sport for the first time. Keep in mind, too, that it’s important for

children to learn to deal with failure. Through trial and error, children

learn to set limits on their own behavior.

* Tiktinsky R, Falk B, Heim M and Martinovitz U. “The Effect of Resistance Training

on the Frequency of Bleeding in Haemophilia Patients: A Pilot Study,” Haemophilia, 8(1),

22-7, 2002.

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For Parents of Infants, Toddlers, and Preschoolers

From infancy, children learn by interacting with their environment, so

you’ll want to provide your child with plenty of opportunities to explore

and play. Infants with bleeding disorders can enjoy the same activities as

other infants. Give your child rattles, mobiles, stuffed animals, mirrors,

and toys to hold. 

As your baby begins to move around—rolling, crawling, and

standing—you’ll need to balance their exploration with safety.

Learning to stand and walk involves many falls for any

toddler. For the child with a bleeding disorder, these

milestones also mean more bruises. At this stage, you may

feel more anxious, but keep in mind that superficial bruises

are common. They are not a concern unless they are

painful and cause your child to have limited movement,

indicating a joint or muscle bleed. 

Toddlers should be encouraged to try running, jumping, climbing, and

riding wheeled toys that are low to the ground. Their playtime should be well

supervised, and they should use appropriate safety equipment, like helmets,

elbow pads, and knee pads. At home, consider putting cushioned, protective

corners on tables, carpeting on hard floors, and gates at the tops and bottoms

of staircases. Toddlers also begin to play more with other children, so be

ready to help your child learn how to play safely and cooperatively.

As toddlers become preschoolers, they’ll be catching, throwing,

skipping, hopping, and using playground equipment. They will develop

exciting new motor skills—and experience falls, bumps, and bruises as

they practice those skills. To prevent serious injury, be sure that playtime

is supervised and that they use safety equipment. Along with their new

motor skills, they’ll also develop new thinking skills, so preschoolers can

begin to tell their parents when they are having a bleed. 

Allowing your child to participate in age-appropriate play activities:

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improves their strength and coordination;

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prepares them to succeed when it’s time to join their peers in

recreational and organized sports;

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builds their self-esteem by helping them develop the same skills as

their peers.

    

            

For Teens and Adults 

If you were physically active as a child, it’s likely you’ll continue to stay

active into your teen and adult years. As time passes, you may need to

switch from one sport or activity to another. While learning a new sport

may be harder for adults, many activities can be modified or equipment

adapted to accommodate the changes in your musculoskeletal system. HTC

staff, especially physical therapists, can also help design or adapt exercise

programs to accommodate any muscle or joint problems you may have. 

When choosing a sport or exercise, it is important for you to consider

your general body build, past bleeding history, and present condition of

your joints. You’ll also want to think about how your joints respond to

treatment. For example, if you’ve had recurrent ankle bleeds, jogging may

not be for you. However, swimming could be a better alternative. 

What about organized sports versus “pick-up” games? While pick-up

games are usually less competitive, they are often not supervised and you

may not have access to the proper safety gear. Though more demanding

and physical, organized sports tend to be better supervised and use

equipment that will protect you.

As you get older, some sports become more physical and possibly more

dangerous. For example, soccer and basketball are often safe for young

children because there is less contact, but these sports can result in serious

knee and ankle injuries in teens and adults. Should you participate in

these sports? It’s a controversial question, particularly for teens and their

parents who may still be involved in their healthcare decisions. One view

is that prohibiting participation in any sport will eliminate the risk of

injury. Another view is that refusing permission to participate might

frustrate teens, making them less likely to cooperate with their parents and

healthcare staff. 

The decision to play certain sports should be made on an individual

basis, weighing the strength of your child’s desire to play, the social and

emotional benefits of playing, and the real and potential risks. 

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Another concern is that playing a sport may increase the frequency of

bleeding episodes. While some bleeding may result from participation in a

sport, healthcare providers and staff members of camps for children with

hemophilia report that there are generally fewer bleeding episodes among

children who are regularly active than among sedentary children. Of

course, if your child regularly bleeds following a particular activity, you

should rethink their participation in that activity.

At school, it’s important that your child participate in physical

education classes, even if some restrictions or modifications are necessary.

Federal law requires that all children in public schools have the

opportunity to participate in physical education, and most schools will

accept a letter from the HTC director stating

that the child can participate in particular

activities. It can be helpful to have a supply

of factor concentrate at school, so your

child can be treated more quickly in case of

a bleed. Children with bleeding disorders

should also wear either a medical

identification bracelet or necklace. 

Sports and games are a part of

childhood and the physical,

social, and emotional benefits

your child will gain should

outweigh most of the concerns about

his participation. In planning for your

school-age child, evaluate each activity for an increased risk of bleeding. If

the risk for major bleeding is minimal, you may want to let your child try

that activity. Of course, a sport that is fun, exciting, and safe for younger

children may be more dangerous as it becomes more competitive. Keep a

long-range view, guiding your child toward activities he’ll still be able to

do when he gets older. And as your child grows, continually evaluate their

choice of sports. 

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For students involved in school-related athletic activities, there must be

honest communication with school personnel about all aspects of your

bleeding disorder. You and your parents should meet with the

appropriate school staff, including the physical education

teacher, the coach, the athletic trainer and the school

nurse. Inviting HTC staff to the meeting is also a good

idea. Together, you’ll set up a plan outlining steps to

take in the event you are injured or experience

a bleed. 

Conditioning

Once any specific muscle or joint weaknesses

have been minimized, you should begin a

general conditioning program.

Conditioning will make you less likely to be injured. Your program should

focus on the muscles you’ll use and the level of endurance you’ll need for

the sport you’ve chosen. For example, a soccer player needs running

endurance, a golfer less so. A total conditioning program includes:

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stretching for improving flexibility;

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the use of resistance equipment or weight training for 

increasing strength;

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aerobic training for improving endurance;

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practicing skills specific to the sport. 

Overexertion can lead to injury, so take it slowly at the beginning and

progress into the program over a period of three to four weeks. Be sure to

include warm-up and cool-down periods in your conditioning program.

Typically lasting about ten minutes, warm-ups consist of stretching the

muscles you’ll be using and performing some light activities similar to

those you’ll be doing in the sport itself. Warming up also gradually

increases your heart rate. After your workout, cool down for ten minutes,

stretching your muscles and gradually decreasing activity to allow your

heart rate to return to normal.

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For People with Mild or 

Moderate Bleeding Disorders

Because they usually bleed only after significant trauma, most people with

mild bleeding disorders can participate in more vigorous activities. While

sports-related bleeds are usually quickly detected in people with severe

bleeding disorders, they may be less obvious in those with mild or

moderate disease. And because people with mild bleeding disorders do not

bleed as often, they may be less likely to recognize the warning signs of a

bleed or they may not seek immediate treatment. They are also less likely

to be on a home therapy program. Even when not severe, a single bleeding

episode can trigger a cycle of recurrent bleeds into an affected joint,

leading to permanent joint damage. Therefore, if your bleeding disorder is

mild, it’s still necessary that you learn the safest ways to participate in

sports. 

If you have a moderate bleeding disorder, the judgment about what

sports or activities will be safe is usually made on the basis of your clinical

history. If that history includes many bleeding episodes similar to someone

with severe disease, sport choices will need to be more conservative. 

Before You Start

Well in advance of starting a new activity, plan to meet with your HTC

staff for an evaluation that includes a thorough musculoskeletal exam.

Even if you have no specific problems, a training program prior to

engaging in a sport can help. Professional and college athletes never

participate in games without prior conditioning. Why should a person

with a bleeding disorder take fewer precautions? It’s especially important

to plan in advance if you have specific muscles or joints that are weak,

because eliminating those weaknesses will take time. 

You’ll also want to speak with HTC staff about the possibility of

having a bleeding episode. It’s important to know the early signs of a

bleed, because delaying treatment could make a minor bleed more

severe. All bleeding episodes should be treated immediately and with the

appropriate medication. Your healthcare provider may recommend

prophylactic factor replacement before certain activities to minimize

your risk of bleeding.

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Normal muscle strength helps support your joints and makes it less likely

that you’ll be injured, and it helps you perform better. How do you know

which muscles you need to strengthen? A physical therapist can do a

muscle strength test that will tell you. The answer also depends on the

activity you are conditioning for. For example, to ride a bike, you’ll need

strong quadriceps — the muscle on the front of your thigh.

As in stretching, if a bleed occurs, immediately stop exercising. Factor

treatment should be started, followed by R.I.C.E. (rest, ice, compression

and elevation). 

Teens and adults with bleeding disorders often have questions about

whether weight-training or power-lifting programs can help or harm their

joints. Weight training builds strength by using increasing numbers of

weights or repetitions, but it’s very important not to put undue stress on

your joints. To avoid injuring the growth plates of their bones, young

teens should not lift heavy weights until they are past puberty. Power

lifting is a competitive sport in which the contestant demonstrates

maximum lifting ability through sudden, quick maneuvers. Power lifting

is NOT recommended for people with bleeding disorders.

Following these guidelines can help you get the maximum benefit from

a weight-training program, with the least amount of risk:

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Goals

Set goals before beginning your program. These goals should be based

on a physical evaluation that identifies any pre-existing musculoskeletal

problems.

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Facility 

The best place to learn weight training is one that is well supervised by

professionals experienced in exercise physiology and sports injuries. As

a beginner, you’ll learn more easily using resistance machines rather

than free weights. Once you’ve mastered the proper technique on

resistance machines, free weights can be safely introduced. Free weights

provide the flexibility needed for a wide variety of movement. They can

be geared for sport-specific training, and they help promote coordination.

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