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“Secret” Rhabdo

With the extensive discussion following the recent article “CrossFit’s Dirty Little Secret” by Eric Robertson, I want to add my thoughts.  My wife, Lisa, and I own a CrossFit affiliate, CrossFit Flagstaff.  I am a member of the CrossFit training staff and I am a practicing emergency physician.  I also wrote the article “The Truth about Rhabdo“, published in the CrossFit Journal in January 2010, where it remains available to the public as a free article.  (This current article is not intended as a general article about exertional rhabdomyolysis (rhabdo); if you wish to read more about the topic, I refer you there, though there are many excellent articles on rhabdo).  While I have a significant association with CrossFit, this article is entirely my own.

I do not know Mr. Robertson or the colleague he writes about in the article, nor do I have any information about the case he describes beyond what is in the article or in the accompanying interview on The Huffington Post.  I will therefore not further comment on this specific case.  I would, however, like to address some of the issues raised by Mr. Robertson.

The title of the article is misleading.  Rhabdo is anything but a secret, at least in the CrossFit community.  I believe CrossFit has done more to educate the general public and its trainers about rhabdo than any other organization, including many related to communities that also carry an association with rhabdo.  (Of note, the United States Military has published numerous excellent articles on the topic.  Their role, however, has been more to inform medical professionals about rhabdo and to develop guidelines for training and operations as opposed to educating the public or the athlete.)  As numerous other commentators have pointed out, CrossFit has published multiple articles on the topic dating back to 2005.  These are available for free to anyone with an internet connection.  Everyone who attends a CrossFit Level I Certificate Course is provided a Level I Training Guide that includes information about rhabdo and any holder of the CrossFit Level I Certificate has passed a test that includes questions about rhabdo.  There is an entire lecture in the CrossFit Level I Certificate Course devoted to the topic of good mechanics and gradual introduction to an appropriate level of intensity.

Mr. Robertson himself mentions Uncle Rhabdo, the admittedly somewhat macabre mascot introduced by CrossFit to help spread the word about the dangers of rhabdo.  One may dislike the irreverent take on a serious topic, but I would argue it is less helpful to use scare tactics that ultimately hinder rational discussion.

Mr. Robertson relates that when his colleague phoned the affiliate where she trained to cancel her membership, explaining that she was in the hospital, the trainer asked “Is it rhabdo?”  This supports the argument that the CrossFit community is informed, at least at some level, about the condition.  Additionally, he notes that “A quick search of the Interwebs reveals copious amounts of information about rhabdo purveyed by none other than CrossFit trainers.”  Mr. Robertson suggests that the number of articles by CrossFit trainers indicates that the incidence of rhabdo must be higher in athletes training with CrossFit than in other training programs, but we must consider that detection and publicity also play a role.  He refers to rhabdo as “extremely rare”, but I would counter that while uncommon, it is also likely to be under-reported and under-diagnosed.  It is also not that rare: as an emergency physician I see several cases per year from patients who have been hiking in the Grand Canyon which is near where I work, and several cases per year from other causes.

We know that CrossFit makes a significant effort to disseminate information about rhabdo.  This naturally results in more awareness, more detection and more articles and publicity.  I believe the CrossFit community is better educated about rhabdo than any other potentially susceptible community, and I know that many athletes at risk for rhabdo train outside the CrossFit community in complete ignorance of it.  (There are undoubtedly CrossFitters also unaware of rhabdo, but from my perspective CrossFit is doing everything it can to spread the word.)

Mr. Robertson states exertional rhabdomyolysis “should never happen.”  I disagree.  I want to be clear: every case of rhabdo is unfortunate, and I wish we could develop athletes and never see it happen.  We should all act to mitigate the risk, but to eliminate the risk is only possible by eliminating the stimulus, which would mean a loss of all the benefits associated with exercise, especially intense exercise.  Of course, there are also risks associated with not exercising.

As in so many things, there is need to assess risk and benefit.  And not just the risk of exercise versus the benefit of exercise, but the risk of not exercising versus the benefit (such as it is) of not exercising, the risks and benefits of training one way versus another, more versus less, intense versus not and on and on.

Some might argue that if training at a level beyond light circuit training or modest distance walking elevates the risk of rhabdo beyond the miniscule (to, perhaps, the merely very small), this training should be reserved for professional athletes.  Do we really want to restrict the power of being a true athlete to only the elite?  Do we want to declare those benefits off limits?  Do we tell the numerous athletes at my gym who are stronger and fitter in their 40s, 50s and beyond than they were in their 20s that this is all reckless and foolish?  Do we send them to other training programs whose approach to rhabdo is to deny and ignore it so everyone can feel how “safe” they are?  Do we send them to training programs that we know are minimally effective so they might genuinely be safe from rhabdo, even though we know it increases their risk of diabetes, hypertension, heart disease, obesity and depression plus deprives them of the sense of vitality they have from training as a true athlete?

I would argue that the only reasonable way to approach this is to educate everyone as much as possible about the risks and benefits and let them decide for themselves.

Does this mean everyone needs to be an expert on rhabdo?  No.  It does mean however that everyone needs to understand that everything they do (or don’t do) carries a risk, and that how they behave influences that risk.  If you want strong health benefits and are okay with modest athletic gains, then be moderate in your training, whether it’s CrossFit or some other program.  Find your level.  Articles about the “extreme” culture notwithstanding, there is plenty of room for this in CrossFit.

If you are somewhat risk tolerant and desire greater fitness and athleticism, hit those workouts harder.  Note that you cannot be completely risk intolerant and realistically train to excel in competition or some other arena.  The training required to support high performance carries risk.  And despite the impression created by numerous articles, while the risks are real, they remain small.  Whatever your choice, if you work out with a trainer, coach, or training partner, make sure they are aware of your desires.

We also need to be aware of what we are at risk of.  The Dirty Little Secret article addresses rhabdo, but of course there are other risks associated with training.  If you choose to train hard for competition, your chance of sustaining orthopedic injury is actually pretty high.  There are no professional athletes in any sport that have not had some kind of injury, and many live with pain and anywhere from mild to considerable disability as a result of their training.  CrossFit is certainly not immune from this, though CrossFit’s preference for functional movement and variance makes injury rates lower than they might otherwise be.

Is injury good?  Arguments about personal growth aside, in general it is not.  But injury is okay if it is not too severe.  Any trainer will have athletes get injured.  The idea is to tune the training so that the balance of injury and performance gain is optimized for the goal of the training.

And what about rhabdo?  Rhabdo, while uncommon, is a real risk of CrossFit, any serious training or many other activities (like hiking in the Grand Canyon), and athletes and coaches should all be wary of it.  But the risk of getting ill from it at all is small, and rhabdo exists on a spectrum.  At one end, rhabdo can kill or lead to permanent disability such as chronic kidney disease and even lifetime dependence on dialysis.  On the other end, rhabdo can mean some all over body soreness, perhaps coupled with some nausea or abdominal pain, which resolves without the athlete ever seeking medical care.  (I am not advocating trying to manage “mild” rhabdo at home without professional guidance.  If you have any concern that you have rhabdo, go to an emergency department.)

So, if there is a spectrum, where do most cases fall?  There isn’t good comprehensive data, but as someone in the CrossFit community who tends to hear about rhabdo, I have yet to hear about a case involving CrossFit that unequivocally led to permanent disability or death.  I am not saying it hasn’t happened or that it can’t happen.  In fact, with hundreds of thousands of people doing CrossFit every day, it is inevitable that it will happen.  But it usually doesn’t.

I have corresponded or spoken with a fair number of athletes who have been hospitalized for rhabdo, some CrossFitters and some not.  I have had the opportunity to review the blood work of many of them.  While they have all had elevated levels of creatine phosphokinase (CPK), few of them have had even mildly elevated levels of creatinine and all that did elevate returned quickly to normal.  CPK indicates the release of muscle cell contents into the bloodstream.  Contrary to what Mr. Robertson says in his article, there is no level of CPK that is unequivocally associated with kidney injury.  We generally assess kidney injury by looking at creatinine levels.  A mildly elevated creatinine is associated with mild kidney injury, a more elevated one, more serious injury.  If that elevated creatinine returns to normal, that indicates recovery of the kidneys.  If it stays high, that suggests permanent injury.  There are other forms of injury that may result from rhabdo.  In the experience of the athletes with which I am familiar, these have also been temporary and mild, though we know they won’t be in every case.

We can mitigate the risk and severity of rhabdo by training smart.  Every athlete and trainer should educate themselves about this.  Scale appropriately, hydrate appropriately, minimize or avoid high-risk movements, and above all, listen to your body.

So if we are interested in training like an athlete, thus elevating our risk of rhabdo from miniscule to very small, and most of the very small number of rhabdo cases, even those that result in hospitalization, result in only temporary disability, how much risk are we really taking?  I do not mean to minimize the experience of those who have had rhabdo and recovered.  They have experienced significant pain and discomfort, lost time at work or school and training, may have had a prolonged recovery and might have large hospital bills.  But they didn’t die.  They are not on lifelong dialysis or seeking a kidney transplant.  Most of the athletes with whom I have corresponded have also returned to training.

I believe CrossFit represents a paradigm shift in how we view fitness and health.  The holy grail of the fitness industry used to be to find some low-effort exercise program or machine or some pill that people could plunk down their money for and suddenly have the body of their dreams.  CrossFit has turned that on its head.  It doesn’t promise easy results but rather hard work.  We pursue not the appearance of absurdly stick-thin fashion models but rather athletic performance and in the process are changing the aesthetic of what is beautiful in both women and men.

Similarly, we consider everyone an athlete.  We understand the give and take of training and recognize the reality that we all live with risk regardless of what we do.  Rhabdomyolysis has always been there; CrossFit has had the courage to bring it into the light.  The way to deal with that risk is to understand it and to manage it, not to deny it or completely avoid it.  To shun that risk all together is to deny ourselves the opportunity to realize much of the potential that is within us.

October 3, 2013: A version of this article is now up on The Huffington Post.

Medical Emergencies at the Gym

Exercise is associated with many health benefits.  Exercise has been shown to be beneficial to those with many medical conditions including established heart disease and prior myocardial infarction (heart attack).1,2

Still, medical emergencies can happen before, during or after exercise.  In vulnerable individuals, exercise may even precipitate a medical emergency.3  The intent of this article is to highlight some of the warning signs associated with non-traumatic (I.e. not resulting from a physical injury) medical emergencies that may occur at the gym and discuss how to manage these occurrences.  While the target audience for this article is trainers and gym owners, much of the information is relevant to anyone, particularly if they spend a fair amount of time exercising or at the gym.

Risk factors for having a sudden medical emergency are familiar to most people, and include known history of medical conditions like heart disease, diabetes or high blood pressure as well as poor physical condition, obesity and so on, but these risk factors are generally not helpful in deciding when a given individual should seek medical care.  If an athlete experiences chest pressure during or after a workout, they should get an ambulance ride to the hospital regardless of whether they are on blood pressure medication with three prior heart attacks or if they are 22 years old, seemingly healthy and came in fifth at the CrossFit Regionals last year.

Much of the information in this article is geared toward identifying symptoms associated with a cardiac event, but medical emergencies include stroke and other vascular events, asthma, choking and many other causes.  Every attempt is made to make the guidelines provided apply generally to all situations, but a healthy dose of common sense will also help identify cases where someone needs emergent medical evaluation.

If someone collapses, immediately activate emergency medical services and manage them according to American Heart Association CPR or similar guidelines.  If an automated external defibrillator (AED) is available, use it.  There is lots of information online at heart.org and everyone is encouraged to at least attend a basic CPR course.  The methods are easy to learn and carry very low risk for transmission of disease to the provider if they use hands-only CPR or other modern protocols which de-emphasize the giving of rescue breaths (mouth-to-mouth).  This training will help prepare one to deal with the obvious medical emergency of collapse and particularly loss of pulse.

While few people would miss the need for acute medical intervention when someone collapses and doesn’t have a pulse, many medical emergencies start out with less obvious signs and symptoms.

Perhaps the most widely known symptom of a cardiac emergency is chest pain, though people are often reluctant to describe what they experience as pain, instead using terms such as tightness or pressure.  Discomfort in the neck or jaw, arms, back or upper abdomen also may be associated with a cardiac event.

Shortness of breath, even without chest discomfort, may be a symptom of a heart attack or other medical emergency.  Needless to say, this is a common experience at the gym even for the healthiest individuals during or immediately following a workout.  The thing to watch for would be shortness of breath that seems out of proportion to the situation or that lasts longer than expected – patients often complain “I just can’t catch my breath” – or for some characteristic that would not be expected for purely exertional symptoms, such as wheezing in an athlete having an asthma attack.

Unfortunately, many other vague symptoms can be associated with a cardiac event: lightheadedness, sweating and nausea among them.  Again, the rule of thumb would be to watch for what seems out of the ordinary for the circumstances.

While less commonly thought of as associated with exercise, strokes also constitute a medical emergency that requires immediate care.  Signs and symptoms of a stroke include sudden headache, confusion or difficulty with word finding, slurred speech, visual changes, incoordination and numbness, tingling or weakness particularly on one side of the face or body.

What constitutes a true medical emergency can often be a challenging judgment call, and when in doubt it is best to send the athlete to an emergency department to let the professionals sort it out.  Occasionally, individuals may prefer to go to an urgent care or doctor’s office, but these facilities will generally not have the resources to evaluate or manage a true emergency and should be reserved for routine medical care or what are clearly more minor issues.

Individuals may also want to avoid the drama or expense of calling an ambulance.  Keep in mind that if the person is experiencing a heart attack or stroke, minutes count, and the amount of time from the start of the event to definitive therapy affects how much heart muscle or brain is lost in the event – often dramatically altering outcome.  In the United States and many other countries, the best course is to activate emergency medical services by calling the established emergency number as soon as possible.

Symptoms that, if unexplained or out of proportion to the circumstance, should prompt an immediate visit to an emergency department:

  1. Chest pain or discomfort.
  2. Shortness of breath or difficulty breathing.
  3. Altered mental status.
  4. Sudden headache (“thunderclap headache”).
  5. Visual changes.
  6. Slurred speech.
  7. Difficulty with word finding, comprehension of language or confusion.
  8. Numbness, tingling or weakness to one side of the face or body.

Note there are many other reasons to go to the emergency department like abdominal pain, persistent vomiting or many infections.  It’s just that the symptoms above are most associated with a very time critical medical emergency.

  1. After a Myocardial Infarction. Retrieved September 27, 2013, from Patient.co.uk: http://www.patient.co.uk/health/Myocardial-Infarction-After-the-MI.htm 

  2. Robert A. Kloner, M. P., & Boris Z. Simkhovich, M. P. J Am Coll Cardiol. Retrieved September 27, 2013, from J Am Coll Cardiol: http://content.onlinejacc.org/article.aspx?articleid=1136443 

  3. Murray A. Mittleman, M. M. Triggering of Acute Myocardial Infarction by Heavy Physical Exertion — Protection against Triggering by Regular Exertion. Retrieved September 27, 2013, from www.nejm.org: http://www.nejm.org/doi/full/10.1056/NEJM199312023292301