Monday, July 17, 2017

Rhabdomyolysis 2

[For many years, I would go to Colorado in the summer to climb a high mountain in the wilderness, after a generally sedentary year.  In addition, I have an as yet undiagnosed gradually progressive neuromuscular disease.  After these climbing experiences, I would invariably be quite stiff and sore.  I would pass darkened urine.  One time, I prevailed on a former colleague in Denver to obtain a CK on me, which was 6,174.  The next year I would return to repeat the same.]

Three years ago, Christina D’Ambrosio went to her first spin class, pedaling fast on a stationary bike to the rhythms of popular music as an instructor shouted motivation.

But Ms. D’Ambrosio, who exercises regularly, found the hourlong class was harder than she anticipated. By the end her legs were sore and wobbly.

“I thought my body just wasn’t used to that kind of muscle ache because it was my first class,” said Ms. D’Ambrosio, a kindergarten teacher from Pleasantville, N.Y.

Over the next two days, her legs throbbed with excruciating pain, her urine turned a dark shade of brown, and she felt nauseated. Eventually she went to a hospital, where she was told she had rhabdomyolysis, a rare but life-threatening condition often caused by extreme exercise. It occurs when overworked muscles begin to die and leak their contents into the bloodstream, straining the kidneys and causing severe pain.

After a two-week hospital stay, Ms. D’Ambrosio was released and has since recovered. Her case was highlighted in April in The American Journal of Medicine along with two other cases of spinning-induced rhabdomyolysis treated by the same doctors.

The report noted that at least 46 other cases of people developing the condition after a spin class were documented in the medical literature, 42 of them in people taking their first class. The report cautioned that the condition was very rare, and not a reason to avoid high-intensity exercise. But the authors said their goal was to raise public awareness so that people who begin a tough new workout program will ease into it to lower their risk of injury…

Rhabdo, as many experts call it, has long been documented among soldiers, firefighters and others whose professions can be physically demanding. An Army study in 2012 estimated that about 400 cases of the condition are diagnosed among active-duty soldiers each year. On occasion there have also been large clusters of college athletes hospitalized with it after particularly grueling workouts…

In 2014, doctors at NewYork-Presbyterian Weill Cornell Medical Center published a report on two patients who arrived at the emergency room with rhabdo shortly after their first spin class. One was a 24-year-old woman hobbled by pain, her legs swollen and feeling “as tight as drums.” She was rushed to surgery, where doctors sliced her thighs open to relieve a dangerous buildup of pressure.

Another study found that between 2010 and 2014, there were 29 emergency room visits for exercise-induced rhabdo at NewYork-Presbyterian alone. Weight lifting, CrossFit, running and P90X were the reasons for some visits. But the most common one was spinning. Dr. Todd S. Cutler, an internist at the hospital and lead author of the study, said the patients all fit a similar profile.

“These are people who are not unfit,” Dr. Cutler said. “They are being pushed too hard, and they’re not trained to do this, and so they get really bad muscle trauma.”

There is some evidence that certain medications, including statins, stimulants and antipsychotic drugs, as well as genetic susceptibilities may contribute to the condition, said Patricia Deuster, a professor of military and emergency medicine at the Uniformed Services University of the Health Sciences.

But in general it occurs when people simply do not give their muscles time to adjust to an aggressive new exercise, experts say. A little damage to muscles is a good thing because that stimulates them to grow and adapt to stress. But when the stress is too great, fibers are destroyed. When that happens they break apart and release compounds that can be harmful to the liver, such as a protein called myoglobin, which causes brown or tea-colored urine, a classic symptom of rhabdo…

Even elite athletes are not immune. Amy Purdy, a bronze-medalist Paralympic snowboarder and “Dancing With the Stars” contestant, went to an exercise class last year after taking three weeks off from her training regimen. The class consisted of a circuit of challenging exercises, she said, including dozens of pull-ups.

“About halfway through I realized my arms were completely fatigued,” she said.

The next morning she could not straighten her left arm. Then it became sore, stiff and swollen, prompting her to go to a hospital. She remained there for eight days as doctors flushed her kidneys with water, she said. She was diagnosed with rhabdo, and when she wrote about the experience on social media she was inundated with responses.

“Thousands of people have reached out to me on my Instagram page who have had it as well,” she said. “Almost everyone was fit before, got it from pull-ups and is trying to figure out the way to get back into fitness without risking a recurrence.”…

Two things can help you avoid rhabdo, said Joe Cannon, an exercise physiologist. Before starting a new program, do a less intense version of it first. That means riding a stationary bike at a moderate pace before starting a spin class, or doing just one set of a weight lifting exercise rather than multiple sets and repetitions. 

But the most important advice is to know your limits: Don’t be afraid to leave a class or to say no to a trainer if you are struggling.

“One thing I’ve noticed when people tell me they’ve gotten rhabdo in the gym is that they gave up their personal power,” said Mr. Cannon, author of “Rhabdo: The Scary Side Effect of Exercise You’ve Never Heard Of.” “They kept doing what the instructor told them to do because they did not want to look weak.”

Brogan M, Ledesma R, Coffino A, Chander P. Freebie Rhabdomyolysis: A Public Health Concern. Spin Class-Induced Rhabdomyolysis. Am J Med. 2017 Apr;130(4):484-487.

Rhabdomyolysis is a pathologic condition in which intracellular muscle constituents leak into the blood circulation. It is usually caused by muscle trauma. "Spinning" is an indoor form of cycling where participants use a special stationary exercise bicycle with a weighted flywheel and undergo high-intensity cycling classes focusing on endurance. There have been several case reports in the literature of exertional rhabdomyolysis following spin class.
Our nephrology practices have diagnosed a number of cases of symptomatic patients presenting to our emergency departments following their first spin classes, with histories and creatinine phosphokinase levels diagnostic of exertional rhabdomyolysis.
We present 3 unusual cases of exertional rhabdomyolysis, each occurring after a first spin class. In the first case, rhabdomyolysis developed following 15 minutes of spin class. In the second case, it occurred in a young individual who exercises regularly. In the third case, the patient developed biopsy-proved acute kidney injury secondary to exertional rhabdomyolysis and required hemodialysis.
The high-intensity exercise associated with "spin class" comes with significant risks to newcomers.

Cutler TS, DeFilippis EM, Unterbrink ME, Evans AT. Increasing Incidence and Unique Clinical Characteristics of Spinning-Induced Rhabdomyolysis. Clin J Sport Med. 2016 Sep;26(5):429-31.

To compare outcomes of spinning-induced rhabdomyolysis to those with exertional rhabdomyolysis from other physical activities.
Retrospective cohort study.
Academic medical center, single-center.
A retrospective chart review was conducted on patients evaluated from December 2010 through November 2014. Patients were selected by ICD-9 code for rhabdomyolysis. Patients were included if the reason for admission was rhabdomyolysis caused by exertion. Cases of rhabdomyolysis caused by trauma or drugs were excluded.
Muscle group involvement, admission, and peak creatine kinase levels, time from activity to hospitalization, length of hospital stay, and incidence of complications.
Twenty-nine cases were reviewed with 14 admissions secondary to spinning. Median admission creatine kinase (73 000 IU/L vs 29 000 IU/L, P = 0.02) and peak creatine kinase levels were significantly higher in the spinning group (81 000 IU/L vs 31 000 IU/L, P = 0.007). Hospital admissions for spinning-induced rhabdomyolysis increased over time.
Health care providers should be aware of the potential dangers of spinning-related rhabdomyolysis especially in otherwise healthy young people.

Courtesy of a colleague

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