Portal de Periódicos da CAPES

Sport and Hemophilia in Italy: An Obstacle Course

2018; Lippincott Williams & Wilkins; Volume: 17; Issue: 7 Linguagem: Inglês

10.1249/jsr.0000000000000499

1537-8918

Giuseppe Lassandro, Carmela Pastore, A. Amoruso, D. Accettura, Paola Giordano,

Knee injuries and reconstruction techniques

Introduction As a science, medicine in its earliest stages consisted of advice and instructions trainers gave their athletes during training and competitions, including the Olympic Games. Herodicus of Selymbra (born on 480 BC), considered the father of sports medicine, was a gymnastics instructor who trained his students in wrestling and boxing to make them stronger and more robust and to keep them in good health (1,2). Nowadays, sports medicine is an integrated multidisciplinary science with different roles: care for and assist athletes in his or her performances; provide preventive clinical evaluations to minimize sports related morbidity and mortality; help people recognize human limits, for example, the doping struggle; spread the culture of well-being with academic research, writing, and public education projects (3). The Italian Sport Medicine Federation (FMSI), founded in 1945 and affiliated with the Italian Olympic Committee, is the public scientific and legal entity to guarantee sport medicine values and functions in Italy. FMSI, among other activities, cooperates with the Italian parliament and/or connected institutions to promulgate laws in sport medicine area (4). Two laws govern the access to organized sport practice by people in Italy. The first (DM 18/02/1982 “Norme per la tutela sanitaria dell’attività sportive agonistica,” or “Health rules for competitive sports practice”) gives the possibility to receive a competitive sport medical certification (5). The second (DM 24/04/2013 “Disciplina della certificazione dell’attività sportiva non agonistica e amatoriale e linee guida sulla dotazione e l'utilizzo di defibrillatori semiautomatici e di eventuali altri dispositivi salva vita,” or “Laws for the certification of non-competitive sport practice and guidelines for the use of semi-automatic defibrillators”) offers skills to not competitive sport medical certification (6). To simplify, “competitive” is the type of activity systematically and continuously practiced by an athlete in one of the structures of the Italian Olympic Committee (for example, National Sport Federations) enabling the participation, although not guaranteed, in the Olympic Games. For these reasons, the competitive certification is sport- and age-specific, with each National Sport Federation establishing the age when competitive tournament starts and the type and periodicity of required health checks. For example, most sports (swimming, hockey, rowing) competition begins at 10 years of age, and the medical exam is valid for a year and requires annual certification. The majority of combat sports require additional examinations, neurological, audiometric, along with the routine, cardiology, general medical, optometry, pulmonary, and laboratory tests. For this reason in the “competitive” philosophy, the certifier is exclusively the physician that specialized in sports medicine (5). The definition of a “not competitive” athlete are students practicing extracurricular sports activities (excluding the national phase of student games which is considered a “competitive” tournament), and all those who participate in organized activities of the Italian Olympic Committee (including activities of National Sport Federations) not included in the DM 18/02/1982. In a nutshell, a “not competitive” athlete plays for fun or well-being without aspiring to Olympic or World games. The certifiers of “not competitive” players are the doctors that specialized in sports medicine and general primary care providers, family physicians, and pediatricians. These medical certificates are valid for a year and require annual validation, of note at the time of the examination, the observation of an electrocardiogram is necessary (6). Hemophilia is an X-linked genetic disorder. People with hemophilia present with a history of easy bleeding. The severity of the disease is determined by the degree of coagulation factor deficiency, either factor VIII in hemophilia A or factor IX in hemophilia B. Severe cases, in which the level of coagulation factor drops below 1% are usually associated with spontaneous intra-articular hemorrhage. Mild (below 40%) and moderate (up 1% and below 5%) decreases suffer predominantly from traumatic bleeding (7). Home treatment has become an important component of hemophilia management. The possibility of a quick treatment with intravenous coagulation factor in the event of bleeding or in prophylaxis effectively prevents dangerous complications and enables patients to lead active lives. Before the implementation of this type of treatment, patients were discouraged from any sport activities due to a high risk of bleeding. Nowadays, hemophiliacs should be encouraged to improve their muscle coordination and strength with sports; in particular, sport activities in children may positively influence the quality of their social life (8–12). Presently, in Italy, there are no specific recommendations for the access of hemophiliacs in organized sports activity. Even worse, there are often different approaches by region, doctors, or clinical practice. As currently constructed, there is the risk of allowing physical activity to those who could experience harm and to not allow it to those who would benefit. Finally, it highlights a great lack of knowledge on sport issues linked to hemophilia. It is thought that participating in sports is an effective collateral therapy for hemophilia but there is a significant dilemma for the certifier: “is it appropriate to issue a certificate of competitive or not competitive type?” The solution to this dilemma has not yet been found because a unique, and the right answer does not exist! A possible approach to solving this conundrum is to individualize the assessment and recommendations. An initial question to ask, is the risk of physical injury the same in “competitive” or “not competitive” practice? The evaluation also must take into account other variables: severity of disease, therapeutic program, comorbidities and complications, joint status, type of sports, place of competitions, health personnel present during practice and competition. The overall risk is determined by clinical history of the patient and by the specific aspects of every sport. Therefore, in our opinion, this assessment should be performed by a physician specializing in bleeding disorders and by a sports medicine doctor. Similarly, to what happens when managing other chronic diseases (for example juvenile diabetes), the specialist prepares a report on clinical history, and the sports medicine doctor evaluates the opportunity of “competitive” or “not competitive” practice and then advises the selection of sport based on physical abilities, risk of bleeding, previous experiences, opinions of caregivers, the parents, and the patient. There are still many steps to be taken to obtain the coveted legislation, but technical meetings (between the scientific community, patients association, and other stakeholders) are already in progress to start traveling down this path. Finally, a few words on recent, major advances in the treatment of hemophilia. The emergence of extended half-life products, factor VIII orthologs, and gene therapy will radically change the patient management. Extended half-life products are manufactured to decrease the frequency of injections, raise the basal level of factor VIII and the orthologs that tend to create less immunogenicity, and possibly gene therapy will result in a cure. In the near future, therapies will be tailored to a patient's needs to include their desired level of physical activity and competition (13,14).