{"id":54597,"date":"2020-02-01T08:00:48","date_gmt":"2020-02-01T13:00:48","guid":{"rendered":"https:\/\/www.policechiefmagazine.org\/?p=54597"},"modified":"2024-12-10T15:18:22","modified_gmt":"2024-12-10T20:18:22","slug":"focus-on-officer-wellness-rhabdomyolysis","status":"publish","type":"post","link":"https:\/\/www.policechiefmagazine.org\/focus-on-officer-wellness-rhabdomyolysis\/","title":{"rendered":"Focus on Officer Wellness: Rhabdomyolysis\u2014More Than Dehydration"},"content":{"rendered":"<p>A 1990 report from the Centers for Disease Control (CDC) noted that,<\/p>\n<p style=\"padding-left: 40px;\"><em>On September 19, 1988, 50 police trainees from local police departments began a 14-week \u201dmental stress\u201d and physical training program at a state-sponsored academy in western Massachusetts. On the evening of September 21, the Massachusetts Department of Public Health was notified that five trainees had been hospitalized.<\/em><\/p>\n<p style=\"padding-left: 40px;\"><em>The first three days of the training program were physically strenuous and included push-ups, squat-thrusts, and running.<\/em><\/p>\n<p style=\"padding-left: 40px;\"><em>All 50 trainees had evidence of rhabdomyolysis (serum CPK greater than or equal to 10 times normal) and 33 (66 percent) had severe rhabdomyolysis (serum CPK greater than or equal to 200 times normal). Thirteen (26 percent) of the trainees were hospitalized with complaints of nausea, back and abdominal pain, and dark urine; each of those hospitalized had serum CPK levels greater than or equal to 32,000 U\/L (normal: 10-300 U\/L) and an abnormal urinalysis. Nine (69 percent) of those hospitalized had evidence of renal insufficiency (serum creatinine greater than or equal to 2.0 mg divided by L); six (46 percent) required hemodialysis. One trainee died 44 days after onset from complications of heat stroke, rhabdomyolysis, and renal and hepatic failure.<\/em><sup>1<\/sup><\/p>\n<p>More than two decades later in 2016, a Texas police recruit died in training, and it was reported that he passed from rhabdomyolysis.<sup>2<\/sup><\/p>\n<p>Rhabdomyolysis is often misconstrued as a form of dehydration. Dehydration may occur at the same time as rhabdomyolysis, but rhabdomyolysis often occurs without dehydration. Conversely, dehydration can occur without rhabdomyolysis. Over the last 10 years, there have been many reports of cases of rhabdomyolysis published in lay and professional literature.<\/p>\n<p>The occurrence of rhabdomyolysis doubled in the military from 2007 to 2011 with 435 cases in 2011 alone. These cases were deemed likely to have been caused by physical exertion and, in some cases, heat stress. The highest incidence was found in males, African Americans, non-Hispanics, and those under the age of 20.<\/p>\n<p>According to a U.S. Army report,<\/p>\n<p style=\"padding-left: 40px;\"><em>Most cases of exertional rhabdomyolysis were diagnosed at installations that support basic combat\/recruit training or major combat units of the Army or the Marine Corps. Medical care providers should consider exertional rhabdomyolysis in the differential diagnosis when service members (particularly recruits) present with muscular pain, swelling, limited range of motion, or the excretion of dark urine (possibly due to myoglobinuria) after strenuous physical activity, particularly in hot, humid weather.<\/em><sup>3<\/sup><\/p>\n<p>So what is \u201crhabdo\u201d? Rhabdomyolysis is the destruction of skeletal muscle. There are many causes of rhabdomyolysis. One cause is extreme muscle strain.<sup>4<\/sup> Extreme muscle strain can come from new exercises, too many sets and repetitions (reps) of an exercise, too much training to failure, too many \u201cnegative\u201d reps of an exercise, and high levels of exercise after a training layoff of even just a few weeks. Of course, if someone is dehydrated, the damage and symptoms can be even worse.<\/p>\n<p>The extreme muscle strain actually damages the muscle membrane and connective tissue structure. The damaged muscle dumps a muscle protein called myoglobin into the blood stream. The high levels of myoglobin in the blood reach the kidney and can block the filtration system in the kidney, which can lead to kidney failure. When the myoglobin levels are this high, the myoglobin spills out into the urine, which can turn tea colored or dark brown.<sup>5<\/sup> This dark urine is a very bad sign, and if this occurs, the person needs to go to an emergency room immediately.<\/p>\n<p>The muscle damage also dumps the electrolyte potassium into the blood. This high level of potassium in the blood is pathologic and can cause a heart attack and death.<\/p>\n<p>The amount of a muscle enzyme known as creatine kinase (CK) in the blood can also skyrocket from muscle damage. This enzyme can also be elevated after a tough workout that does not cause rhabdomyolysis, but, in cases of rhabdomyolysis, the CK blood levels are incredibly elevated. One study of military personnel found that the length of hospital stay was related to the elevation of CK; the higher the CK levels, the longer the hospital stay. The patients in the 30 cases of rhabdomyolysis in this study were hospitalized for one to eight days and 20 percent had acute kidney damage.<sup>6<\/sup><\/p>\n<p>Patients with rhabdomyolysis experience severe muscle pain and stiffness and sometimes describe having flu-like symptoms. Blood and urine tests confirm the diagnosis of rhabdomyolysis. Some patients are admitted into hospitals for intravenous fluids to keep kidney filtration going, and they may even require short-term dialysis. Time is required for the muscles to heal and resuming activity or training too soon can lead to further muscle damage.<\/p>\n<p>Swelling from the damaged muscle can occur, and, if this occurs in a small anatomic compartment, then compartment syndrome can occur. The high pressure in compartment syndrome is a medical emergency, and the compartment must be surgically decompressed (opened) before other structures in the compartment such as nerves and blood vessels are crushed and permanently damaged or die.<\/p>\n<p>Even though rhabdomyolysis is not a daily occurrence, as shown from the cases in the sidebar, it does occur. The literature is filled with many other reports of athletes being admitted to hospitals for rhabdomyolysis. Fortunately, this entirely avoidable problem is gaining more attention, which should lead to improved education to help athletes, military personnel, and first responders avoid it.<\/p>\n<p>The President of the National Strength and Conditioning Association stated,<\/p>\n<p style=\"padding-left: 40px;\"><em>This type of injury is 100 percent avoidable. This should have never happened. That\u2019s absurd. People need to understand that rhabdo is not inherent with training. It\u2019s a good indicator of a training program that is inappropriate.<\/em><sup>7<\/sup><\/p>\n<p>Medical and strength and conditioning authorities note that conditioning specialists need to be educated about rhabdo. The severe consequences of rhabdomyolysis include emergent medical intervention. Legal action and consequences usually follow.<\/p>\n<p>Steps can be taken to reduce the risk of the occurrence of rhabdomyolysis in training.<\/p>\n<ul>\n<li>Make sure the trainees are in good physical condition to begin training.<\/li>\n<li>Avoid sudden increases in training, especially if there has been a break from training for even just a few weeks.<\/li>\n<li>Introduce new exercises gradually.<\/li>\n<li>Follow established, evidence-based program designs that have a progression of training loads and intensity and recovery, with short-term and mid-term goals.<\/li>\n<li>Avoid the use of physical training as punishment. The added training load on a trainee who is already lagging may be the very thing that lands him or her in a hospital\u2019s intensive care unit.<\/li>\n<li>Ensure proper hydration and avoid heat exertion as these factors may contribute to rhabdomyolysis (although they are not the cause).<\/li>\n<li>Make sure trainees have been advised to notify instructors or coaches of their urine becoming darker. At this point, medical attention is needed, especially if there is excessive soreness and flu-like symptoms.<\/li>\n<li>Listen to trainees. If they are reporting muscle soreness and tightness, the training load must decrease for a short time so further muscle damage does not reach a critical point of rhabdomyolysis. Even under the same training load, some trainees may develop rhabdomyolysis while others will not. Individual variability is real, and the underlying factors that can predispose one trainee to develop rhabdo while others do not are not always understood.<\/li>\n<li>Continually re-evaluate the training plan to make sure it is appropriate and progress is occurring and that injuries are minimized.<\/li>\n<li>Rhabdomyolysis can occur in fit athletes as well if the conditioning program is not well designed.<\/li>\n<\/ul>\n<blockquote><p><span style=\"color: #672767;\">The body is capable of incredible adaptation, but it must be given the chance to recover and adapt.<\/span><\/p><\/blockquote>\n<p>The body is capable of incredible adaptation, but it must be given the chance to recover and adapt. It\u2019s important to remember the goal of putting trainees through a conditioning program\u2014to increase fitness and performance. If an evidence-based program of progressive training loads and recovery is employed, the goal will be achieved. The result will be healthier trainees with higher fitness and performance levels and greatly reduced exposure to injury and litigation.<span style=\"font-family: Webdings;\">d<\/span><\/p>\n<aside class=\"pullout pullout--wide alignleft\"><\/p>\n<h4 class=\"Figures---Sidebars_Side-Bar-Title\"><strong>Case Examples of Rhabdomyolysis<\/strong><\/h4>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\"><em><strong><span class=\"CharOverride-6\">2001:<\/span><\/strong><\/em>\u00a0A study noted two cases of military recruits who were hospitalized for exertional rhabdomyolysis. While both recovered, activity modification was required for one to two months before normal activity could be resumed.<\/p>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\"><em><strong><span class=\"CharOverride-6\">2010:<\/span><\/strong>\u00a0<\/em>Two dozen Oregon high school football players went to a hospital with rhabdomyolysis. Thirteen players were admitted to the hospital, and three had surgery for compartment syndrome. It is reported that they had grueling workouts with a new coach.<\/p>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\"><em><strong><span class=\"CharOverride-6\">2011:<\/span><\/strong><\/em>\u00a0Thirteen University of Iowa football players were admitted for rhabdomyolysis and placed on IV fluids following strenuous workouts of squats, sled pushing, sprints, and upper body exercises. Some of the players even required dialysis. A committee was appointed to investigate the workouts that led to so many players having rhabdomyolysis. This particular workout will not be performed again at the university. At least one player filed a lawsuit for negligence and the expenses of ongoing medical care.<\/p>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\"><em><strong><span class=\"CharOverride-6\">2013:<\/span><\/strong><\/em>\u00a0Six Ohio State University women\u2019s lacrosse players were hospitalized for rhabdomyolysis. Dr. Kelsey Logan, a university-affiliated physician who serves on the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports reported,<\/p>\n<p class=\"Inline-Quote\" style=\"padding-left: 40px;\"><em><span class=\"CharOverride-83\">T<\/span><span class=\"CharOverride-83\">here are two reasons why this is important. One is that rhabdo can have potentially serious consequences: renal failure, compartment syndrome, death. Those are fairly serious. And the second thing is we know there are certain circumstances under which this is more likely to occur, and with fairly simple educational and practical techniques for prevention, those circumstances can be lessened so much.<\/span><\/em><\/p>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\"><em><strong><span class=\"CharOverride-6\">2016:<\/span><\/strong><\/em>\u00a0Eight Texas Women\u2019s University volleyball players were hospitalized for rhabdomyolysis. The team\u2019s doctor stated that as a result of the diagnosis,<\/p>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\" style=\"padding-left: 40px;\"><em><span class=\"CharOverride-84\">[The university] is undergoing a 360-degree investigation involving internal and external experts who are exploring all possibilities, including athletics practice, physical conditioning, nutrition, and hydration. The university is committed to being as transparent as federal privacy and medical privacy laws allow, while respecting the privacy and wishes of students.<\/span><\/em><\/p>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\"><strong><em><span class=\"CharOverride-6\">2016<\/span>:<\/em><\/strong> A Florida police recruit was diagnosed with rhabdomyolysis following an intense physical training sessions within the first days of the academy.*<\/p>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\"><em><strong><span class=\"CharOverride-6\">2017:<\/span><\/strong><\/em>\u00a0A California police recruit was diagnosed with rhabdomyolysis following an intense physical training session. He was two weeks from completing the academy program when he was admitted to the hospital for treatment including intravenous fluids for five days.<\/p>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\"><em><strong><span class=\"CharOverride-6\">2018:<\/span><\/strong><\/em>\u00a0Devon Coney was rushed to the hospital on June 25\u2014his first day of training with the Austin Fire Department. He and another recruit were hospitalized with rhabdomyolysis. Devon died the next day. An outside third party is investigating the fire department\u2019s training practices.<\/p>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\"><em><strong><span class=\"CharOverride-6\">2018:<\/span><\/strong><\/em> Cleveland, Ohio, police officer Vu Nguyen collapsed during a timed run and died from rhabdomyolysis. According to his family, Officer Nguyen \u201cwas super-strong and super agile\u2026very healthy, didn\u2019t drink, [and] didn\u2019t smoke.\u201d<\/p>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\"><strong>Note:<\/strong><\/p>\n<p class=\"Figures---Sidebars_Sidebar-Paragraph\">*U.S. Department of Justice, \u201cRhabdomyolysis,\u201d <em><a href=\"https:\/\/cops.usdoj.gov\/html\/dispatch\/index.html\" target=\"_blank\" rel=\"noopener noreferrer\">The Beat<\/a> <\/em>(podcast), Office of Community Oriented Policing Services, July 2018.<\/aside>\n<p><strong>Notes:\u00a0<\/strong><\/p>\n<p><sup>1<\/sup> \u201c<a href=\"https:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/00001812.htm\">Exertional Rhabdomyolysis and Acute Renal Impairment\u2014New York City and Massachusetts, 1988<\/a>,\u201d <em>Morbidity and Mortality Weekly Report<\/em> 39, no. 42 (October 26, 1990):751\u2013756.<\/p>\n<p><sup>2<\/sup> Ryan Osborne, \u201c<a href=\"https:\/\/www.star-telegram.com\/news\/state\/texas\/article118548928.html\">Frisco Police Cadet Dies After Collapsing in Final Training Exercise<\/a>,\u201d <em>Fort Worth Star-Telegram<\/em>, December 2, 2016.<\/p>\n<p><sup>3<\/sup> \u201c<a href=\"https:\/\/health.mil\/News\/Articles\/2019\/04\/01\/Update-Exertional-Rhabdomyolysis\">Update: Exertional Rhabdomyolysis, Active Component, U.S. Armed Forces, 2014-2018<\/a>,\u201d <em>Medical Surveillance Monthly Report<\/em> 26, no. 4 (March 2012): 21\u201325.<\/p>\n<p><sup>4<\/sup> \u201c<a href=\"http:\/\/www.webmd.com\/a-to-z-guides\/rhabdomyolysis-symptoms-causes-treatments#1\">Rhabdomyolysis<\/a>,\u201d <em>A to Z Guides<\/em>, WebMD.<\/p>\n<p><sup>5<\/sup> Siamak N. Nabili, \u201c<a href=\"https:\/\/www.medicinenet.com\/rhabdomyolysis\/article.htm\">Rhabdomyolysis<\/a>,\u201d Medicine Net.<\/p>\n<p><sup>6<\/sup> Robert C. Oh et al., \u201c<a href=\"https:\/\/doi.org\/10.7205\/MILMED-D-14-00274\">Exertional Rhabdomyolysis: A Case Series of 30 Hospitalized Patients<\/a>,\u201d <em>Military Medicine<\/em> 180, no. 2 (February 2015): 201\u2013207.<\/p>\n<p><sup>7<\/sup> Todd Jones, \u201c<a href=\"https:\/\/www.dispatch.com\/article\/20130309\/NEWS\/303099822\">Rhabdomyolysis Laid Low 6 Athletes<\/a>,\u201d <em>Columbus Dispatch<\/em>, March 9, 2013.<\/p>\n<hr \/>\n<p>Please cite as<\/p>\n<p style=\"padding-left: 40px;\">Joseph Horrigan and Joseph Dulla, \u201cRhabdomyolysis\u2014More Than Dehydration,\u201d Focus on Officer Wellness, <em>Police Chief<\/em>\u00a087, no. 2 (February 2020): 14\u201316.<\/p>\n","protected":false},"excerpt":{"rendered":"<p class=\"Departments_Department-Paragraph ParaOverride-31\"><span class=\"Department-first-paragraph CharOverride-80\">A\u00a0<\/span><span class=\"Department-first-paragraph CharOverride-80\">1990 report from the Centers for Disease Control (CDC) noted that,<\/span><\/p>\n<p class=\"Inline-Quote ParaOverride-10\"><em>On September 19, 1988, 50 police trainees from local police departments began a 14-week \u201dmental stress\u201d and physical training program at a state-sponsored academy in western Massachusetts. On the evening of September 21, the Massachusetts Department of Public Health was notified that five trainees had been hospitalized.<\/em><\/p>\n<p class=\"Inline-Quote ParaOverride-10\">The first three days of the training program were physically strenuous and included push-ups, squat-thrusts, and running.<\/p>\n","protected":false},"author":10551,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[152,156],"tags":[1335,1336,1346],"class_list":["post-54597","post","type-post","status-publish","format-standard","hentry","category-columns","category-focus-officer-wellness","tag-dehydration","tag-muscle-strain","tag-rhabdomyolysis"],"acf":{"post_author":"Joseph Horrigan, DC, DACBSP, Executive Director, Tactical Sports Medicine, and Joseph Dulla, MA, TSAC-F, Faculty, Law Enforcement and Public Safety Leadership, University of San Diego, California","main_category":"Focus on Officer Wellness","legacy_article_id":"","legacy_issue_id":"","subtitle":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v23.8 (Yoast SEO v24.1) - 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