Physical Activity in People with Hemophilia

Hemophilia is a rare inherited bleeding disorder associated with recurrent musculoskeletal bleeding, chronic pain, and functional decline. Advances in prophylactic therapies, including extended half-life factors, non-factor therapies like emicizumab, and gene therapies, have fundamentally transformed care, enabling a paradigmatic shift from activity restriction to promotion. This review synthesizes recent evidence to examine the multifaceted role of physical activity (PA) in people with hemophilia (PwH), current challenges, and strategies to optimize health outcomes. PA confers substantial benefits for PwH, improving muscle strength, coordination, bone density, cardiovascular fitness, mental health, and quality of life. It modulates chronic pain through neuroplastic, anti-inflammatory, and neuroendocrine mechanisms, while exercise-derived molecules (exerkines) may directly influence cartilage health. With individualized prophylaxis and structured programming, both resistance and aerobic exercise can be prescribed safely using evidence-based risk stratification (categories I-III) and comprehensive monitoring approaches, including accelerometers, questionnaires, and subjective effort scales. Persistent barriers include chronic pain, fear of injury, insufficient professional guidance, and treatment inequities, while facilitators encompass enjoyment, social support, and adequate prophylactic coverage. Therapies providing continuous hemostatic protection have further expanded safe PA opportunities, supporting participation in previously restricted activities. In this new therapeutic era, PA should be recognized as a fundamental pillar alongside medical care. Not only for musculoskeletal preservation, but also as a strategy promoting metabolic and mental health. Ensuring access for all patients to both advanced therapies and tailored PA prescription, supported by education, enabling policies, and multidisciplinary care, is essential for democratizing active lifestyles within the global hemophilia community.