Eligibility for competitive sport medical certification of children with severe hemophilia: italian observational study.

Main Article Content

Giuseppe Lassandro
Carmela Pastore
Anna Amoruso
Valentina Palladino
Domenico Accettura
Andrea Buzzi
Silvio Tafuri
Maria Filomena Gallone
Roberto Valente
Rodrigo Trisciuzzi
Cristina Cassone
Paola Giordano


Children, Sport, Hemophilia, Arthropathy


Background ad aim of workː the position of Italian law regarding participation of prophylactically treated hemophiliacs to organized sport trainings and competitions remains unclear and this study focuses on the eligibility of pediatric patients in particular.
Methodsː 16 patients age 3 to 15 years old, with severe haemophilia and prophylaxis starting age of 20,2 ± 2,2 months were enrolled. Weight, height, body mass index (BMI) and joint status (Hemophilia Joint Health Score [HJHS] and Haemophilia Early Arthropathy Detection with UltraSound, HEAD-US score) of patients were evaluated at start (T0) and after 12 months (T12) of a HIITS sport activity program.
Resultsː All patients qualified for Italian competitive sport medical certification. Their weight and height increased after 12 months, without an increase in BMI (T0= 17,2; T1= 18,7; p>0,05). HJHS score did not change significantly (T0: 1.6 ± 1; T1: 2.1 ± 1.3; p>0.05). All children were right-handed and atrophy for the muscles of the right elbow significantly decreased (no atrophy seen at T0 in 4 of 16 patients and at T1 in 8 of 16 patients; p=0.045).
Conclusionsː Hemophilic children, prophylactically treated, are capable to be included in sport groups and physical activity programs.


Download data is not yet available.
Abstract 0 |


1. Stonebraker, J. S., Bolton-Maggs, P. H., Michael Soucie, J., Walker, I., & Brooker, M. (2012). A study of variations in the reported haemophilia B prevalence around the world. Haemophilia: the official journal of the World Federation of Haemophilia, 18(3), e91–e94. https://doi.org/10.1111/j.1365-2516.2011.02588.x.
2. Stonebraker, J. S., Bolton-Maggs, P. H., Soucie, J. M., Walker, I., & Brooker, M. (2010). A study of variations in the reported haemophilia A prevalence around the world. Haemophilia: the official journal of the World Federation of Haemophilia, 16(1), 20–32. https://doi.org/10.1111/j.1365-2516.2009.02127.x.
3. Bolton-Maggs, P. H., & Pasi, K. J. (2003). Haemophilias A and B. Lancet (London, England), 361(9371), 1801–1809. https://doi.org/10.1016/S0140-6736(03)13405-8.
4. Manco-Johnson MJ, Abshire TC, Shapiro AD, Riske B, Hacker MR, Kilcoyne R, Ingram JD, Manco-Johnson ML, Funk S, Jacobson L, Valentino LA, Hoots WK, Buchanan GR, DiMichele D, Recht M, Brown D, Leissinger C, Bleak S, Cohen A, Mathew P, Matsunaga A, Medeiros D, Nugent D, Thomas GA, Thompson AA, McRedmond K, Soucie JM, Austin H, Evatt BL. (2007) Prophylaxis versus episodic treatment to prevent joint disease in boys with severe hemophilia. N Engl J Med. 9;357(6):535-44. doi: 10.1056/NEJMoa067659. PMID: 17687129.
5. Giordano, P., Franchini, M., Lassandro, G., Faienza, M. F., Valente, R., & Molinari, A. C. (2013). Issues in pediatric haemophilia care. Italian journal of pediatrics, 39, 24. https://doi.org/10.1186/1824-7288-39-24
6. Iorio, A. (2017). Using pharmacokinetics to individualize hemophilia therapy. Hematology. American Society of Hematology. Education Program, 2017(1), 595–604. https://doi.org/10.1182/asheducation-2017.1.595.
7. Witmer, C. M. (2019). How I approach managing student athletes at risk for bleeding. Pediatric blood & cancer, 66(2), e27523. https://doi.org/10.1002/pbc.27523.
8. Souza, J. C., Simoes, H. G., Campbell, C. S., Pontes, F. L., Boullosa, D. A., & Prestes, J. (2012). Haemophilia and exercise. International journal of sports medicine, 33(2), 83–88. https://doi.org/10.1055/s-0031-1286292.
9. Negrier, C., Seuser, A., Forsyth, A., Lobet, S., Llinas, A., Rosas, M., & Heijnen, L. (2013). The benefits of exercise for patients with haemophilia and recommendations for safe and effective physical activity. Haemophilia: the official journal of the World Federation of Haemophilia, 19(4), 487–498. https://doi.org/10.1111/hae.12118.
10. Douma-van Riet, D. C., Engelbert, R. H., van Genderen, F. R., Ter Horst-De Ronde, M. T., de Goede-Bolder, A., & Hartman, A. (2009). Physical fitness in children with haemophilia and the effect of overweight. Haemophilia: the official journal of the World Federation of Haemophilia, 15(2), 519–527. https://doi.org/10.1111/j.1365-2516.2008.01928.x.
11. Gomis, M., Querol, F., Gallach, J. E., González, L. M., & Aznar, J. A. (2009). Exercise and sport in the treatment of haemophilic patients: a systematic review. Haemophilia: the official journal of the World Federation of Haemophilia, 15(1), 43–54. https://doi.org/10.1111/j.1365-2516.2008.01867.x.
12. Srivastava, A., Brewer, A. K., Mauser-Bunschoten, E. P., Key, N. S., Kitchen, S., Llinas, A., Ludlam, C. A., Mahlangu, J. N., Mulder, K., Poon, M. C., Street, A., & Treatment Guidelines Working Group on Behalf of The World Federation Of Haemophilia (2012). Guidelines for the management of haemophilia. Haemophilia: the official journal of the World Federation of Haemophilia, 19(1), e1–e47. https://doi.org/10.1111/j.1365-2516.2012.02909.x.
13. Wagner, B., Seuser, A., Krüger, S., Herzig, M. L., Hilberg, T., Ay, C., Hasenöhrl, T., & Crevenna, R. (2019). Establishing an online physical exercise program for people with haemophilia. Wiener klinische Wochenschrift, 131(21-22), 558–566. https://doi.org/10.1007/s00508-019-01548-1.
14. Maffet, M., & Roton, J., Jr (2017). Haemophilia in Sports: A Case Report and Prophylactic Protocol. Journal of athletic training, 52(1), 65–70. https://doi.org/10.4085/1062-6050-51.11.14.
15. Giordano, P., Lassandro, G., Valente, M., Molinari, A. C., Ieranò, P., & Coppola, A. (2014). Current management of the haemophilic child: a demanding interlocutor. Quality of life and adequate cost-efficacy analysis. Pediatric hematology and oncology, 31(8), 687–702. https://doi.org/10.3109/08880018.2014.930768.
16. Decree of the Ministry of Health. Rules for the health protection of competitive sports activity.1982;No.63. http://www.fmsi.it/images/pdf/leggi/DM.1982_n.82_tutela_sanitaria_att_agonistica.pdf.
17. Decree of the Ministry of Health, (2013) Discipline of the certification of non-competitive and amateur sports activities and guidelines on the equipment and use of semi-automatic defibrillators and any other life-saving devices. http://www.fmsi.it/images/pdf/leggi/dm24042013-20130122.zip (last access 27/12/2017).
18. Lassandro, G., Pastore, C., Amoruso, A., Accettura, D., & Giordano, P. (2018). Sport and Haemophilia in Italy: An Obstacle Course. Current sports medicine reports, 17(7), 230–231. https://doi.org/10.1249/JSR.0000000000000499.
19. Feldman, B. M., Pai, M., Rivard, G. E., Israels, S., Poon, M. C., Demers, C., Robinson, S., Luke, K. H., Wu, J. K., Gill, K., Lillicrap, D., Babyn, P., McLimont, M., Blanchette, V. S., & Association of Hemophilia Clinic Directors of Canada Prophylaxis Study Group (2006). Tailored prophylaxis in severe hemophilia A: interim results from the first 5 years of the Canadian Hemophilia Primary Prophylaxis Study. Journal of thrombosis and haemostasis : JTH, 4(6), 1228–1236. https://doi.org/10.1111/j.1538-7836.2006.01953.x
20. Feldman, B. M., Funk, S. M., Bergstrom, B. M., Zourikian, N., Hilliard, P., van der Net, J., Engelbert, R., Petrini, P., van den Berg, H. M., Manco-Johnson, M. J., Rivard, G. E., Abad, A., & Blanchette, V. S. (2011). Validation of a new pediatric joint scoring system from the International Haemophilia Prophylaxis Study Group: validity of the haemophilia joint health score. Arthritis care & research, 63(2), 223–230. https://doi.org/10.1002/acr.20353.
21. Martinoli, C., Della Casa Alberighi, O., Di Minno, G., Graziano, E., Molinari, A. C., Pasta, G., Russo, G., Santagostino, E., Tagliaferri, A., Tagliafico, A., & Morfini, M. (2013). Development and definition of a simplified scanning procedure and scoring method for Haemophilia Early Arthropathy Detection with Ultrasound (HEAD-US). Thrombosis and haemostasis, 109(6), 1170–1179. https://doi.org/10.1160/TH12-11-0874.
22. Anderson A, Forsyth A (2017). Playing It Safe—Bleeding Disorders, Sports and Exercise. New York, NY: National Haemophilia Foundation.
23. Eddolls, W., McNarry, M. A., Stratton, G., Winn, C., & Mackintosh, K. A. (2017). High-Intensity Interval Training Interventions in Children and Adolescents: A Systematic Review. Sports medicine (Auckland, N.Z.), 47(11), 2363–2374. https://doi.org/10.1007/s40279-017-0753-8.
24. McLain, L. G., & Heldrich, F. T. (1990). Hemophilia and Sports. The Physician and sportsmedicine, 18(11), 73–80. https://doi.org/10.1080/00913847.1990.11710175.
25. American with Disabilities Act, The Rehabilitation Act, Public Law 93-112, 87 stat. 355. Internet.
Archive Web site. https://archive.org/stream/publiclaw931129300unit#page/nl/mode/2up. 26. Cornet, J., (2007) . Congress passes new laws beneficial to people with bleeding disorders. Hemophilia of Georgia Web site. http://www.hog.org/publications/detail/congress-passes-new-laws-beneficial-to-people-with-bleeding-disorders.
27. Pelletier, J., Q., D,. G reatest Hockey Legends Web site.
28. Fromme, A., Dreeskamp, K., Pollmann, H., Thorwesten, L., Mooren, F. C., & Völker, K. (2007). Participation in sports and physical activity of haemophilia patients. Haemophilia : the official
journal of the World Federation of Hemophilia, 13(3), 323–327. https://doi.org/10.1111/j.1365-2516.2007.01456.x
29. Köiter, J., van Genderen, F. R., Brons, P. P., & Nijhuis-van der Sanden, M. W. (2009). Participation and risk-taking behaviour in sports in children with haemophilia. Haemophilia : the official journal of the World Federation of Hemophilia, 15(3), 686–694. https://doi.org/10.1111/j.1365-2516.2009.02006.x
30. Sherlock, E., O'Donnell, J. S., White, B., & Blake, C. (2010). Physical activity levels and participation in sport in Irish people with haemophilia. Haemophilia : the official journal of the World Federation of Hemophilia, 16(1), e202–e209. https://doi.org/10.1111/j.1365-2516.2009.02111.x
31. Negri, L., Buzzi, A., Aru, A. B., Cannavò, A., Castegnaro, C., Fasulo, M. R., Lassandro, G., Rocino, A., Santoro, C., Sottilotta, G., Giordano, P., Mazzucconi, M. G., Mura, R., Peyvandi, F., & Delle Fave, A. (2020). Perceived well-being and mental health in haemophilia. Psychology, health & medicine, 1–11. Advance online publication. https://doi.org/10.1080/13548506.2020.1717556.
32. Gazzetta Ufficiale della Repubblica Italiana, (1987) Legge 16 marzo 1987 n° 115 “Disposizioni per la prevenzione e cura del diabete mellito”- https://www.gazzettaufficiale.it/atto/serie_generale/caricaDettaglioAtto/originario?atto.dataPubblicazioneGazzetta=1987-03-26&atto.codiceRedazionale=087U0115&elenco30giorni=false
33. Olivieri, M., Königs, C., Heller, C., Horneff, S., Oldenburg, J., Halimeh, S., Kentouche, K., Knöfler, R., Fischer, L., Pfrepper, C., Kurnik, K., & Bidlingmaier, C. (2019). Prevalence of Obesity in Young Patients with Severe Haemophilia and Its Potential Impact on Factor VIII Consumption in Germany. Hamostaseologie, 39(4), 355–359. https://doi.org/10.1055/s-0039-1677874
34. Wilding, J., Zourikian, N., Di Minno, M., Khair, K., Marquardt, N., Benson, G., Ozelo, M., & Hermans, C. (2018). Obesity in the global haemophilia population: prevalence, implications and
expert opinions for weight management. Obesity reviews : an official journal of the International Association for the Study of Obesity, 19(11), 1569–1584. https://doi.org/10.1111/obr.12746
35. Chang, C. Y., Li, T. Y., Cheng, S. N., Pan, R. Y., Cheng, C. N., Wang, H. J., Hu, S. H., & Chen, Y. C. (2019). Obesity and overweight in patients with hemophilia: Prevalence by age, clinical correlates, and impact on joint bleeding. Journal of the Chinese Medical Association : JCMA, 82(4), 289–294. https://doi.org/10.1097/JCMA.0000000000000047
36. Giordano, P., Brunetti, G., Lassandro, G., Notarangelo, L. D., Luciani, M., Mura, R. M., Lazzareschi, I., Santagostino, E., Piacente, L., Ventura, A., Cavallo, L., Grano, M., & Faienza, M. F. (2016). High serum sclerostin levels in children with haemophilia A. British journal of haematology, 172(2), 293–295. https://doi.org/10.1111/bjh.13481.
37. Ross, C., Goldenberg, N. A., Hund, D., & Manco-Johnson, M. J. (2009). Athletic participation in severe haemophilia: bleeding and joint outcomes in children on prophylaxis. Pediatrics, 124(5), 1267–1272. https://doi.org/10.1542/peds.2009-0072.
38. Yıldız, M., Özdemir, N., Önal, H., Koç, B., Eliuz Tipici, B., & Zülfikar, B. (2019). Evaluation of Unfavorable Cardiovascular and Metabolic Risk Factors in Children and Young Adults with Haemophilia. Journal of clinical research in pediatric endocrinology, 11(2), 173–180. https://doi.org/10.4274/jcrpe.galenos.2018.2018.0292
39. Valente, M., Cortesi, P. A., Lassandro, G., Mathew, P., Pocoski, J., Molinari, A. C., Mantovani, L. G., & Giordano, P. (2015). Health economic models in haemophilia A and utility assumptions from a clinician's perspective. Pediatric blood & cancer, 62(10), 1826–1831. https://doi.org/10.1002/pbc.25543.
40. Schiavoni, M., Napolitano, M., Giuffrida, G., Coluccia, A., Siragusa, S., Calafiore, V., Lassandro, G., & Giordano, P. (2019). Status of Recombinant Factor VIII Concentrate Treatment for Haemophilia a in Italy: Characteristics and Clinical Benefits. Frontiers in medicine, 6, 261. https://doi.org/10.3389/fmed.2019.00261.
41. Gollomp, K. L., Doshi, B. S., & Arruda, V. R. (2019). Gene therapy for hemophilia: Progress to date and challenges moving forward. Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis, 58(5), 602–612. https://doi.org/10.1016/j.transci.2019.08.012.).

Most read articles by the same author(s)