I had no idea that this was possible
Extreme Conditioning Programs and Exertional Rhabdomyolysis
Public Health Advisory from the Director of Force Health Protection
On 18 May 2012, a Base Surgeon notified the Directorate Force Health Protection (D FHP) of three cases of rhabdomyolysis requiring hospitalization; one case required dialysis for acute renal failure. Two of three cases reported doing “CrossFit®”, a type of Extreme Conditioning Program (ECP), prior to their diagnosis. The three cases originated from the same base and presented to the medical clinic over a short time period between March and May, 2012.
Exertional rhabdomyolysis (ER) has been reported most commonly in weight lifters, endurance athletes, and military personnel (particularly at the recruit level). It is associated with considerable morbidity in terms of lost duty time, hospitalization, and medical treatment. Although few studies have examined the burden of this illness in civilian and military populations, a recent descriptive study using hospital and administrative data of the active component of the U.S. Armed Forces found the diagnosis of ER increased by 70 percent from 2006 to 2010. This study noted that personnel were more likely to develop ER if they were male, less than 26 years of age, were African-American, had a length of service of less than 90 days, suffered from a previous heat injury and had not deployed during the study period. (reference A).
As ER can be associated with potentially life threatening complications, a preliminary investigation was initiated to identify other possible cases of rhabdomyolysis in CF personnel to determine the magnitude of the problem. Laboratory reports with an elevated creatine kinase (CK) level of greater than 4,000 U/L from the Canadian Forces Health Information System (CFHIS) were used to identify additional cases. Twenty-one cases were identified between April 2011 and May 2012. Health record review found 18 of these 21 cases had participated in some form of exercise/fitness program, workout, or competition. Documentation in 10 of 18 health records specifically mentioned CrossFit® as a possible risk factor. These numbers likely represent an underestimate of the true incidence of rhabdomyolysis since only the most severe cases were captured (i.e., the cases had a CK value greater than 4,000 U/L, sought medical attention at a CF medical treatment facility and discrete laboratory data is only available at about half of all CFHIS sites).
ECPs, such as CrossFit®, P90x®, and Insanity®, have increased in popularity over the past few years. These programs are characterized by frequent, repetitious, high intensity exercises with very short rest periods between sets/cycles and little recovery time between workouts. Some ECPs do not encourage participants to progressively increase their workloads in an effort to allow for training adaption. CF personnel who participate may not have the requisite knowledge to properly set the required work to rest ratios to offset injury or illnesses possibly associated with ECPs. A disproportionate number of injuries such as muscle strains, sprains, stress fractures and rhabdomyolysis associated with ECPs have been cited in anecdotal reports and case studies, however, few studies have looked at the relationship between ECPs and injuries to date. (reference B)
ECPs are not endorsed by Personnel Support Programs (PSP), Directorate of Fitness (DFIT) or D FHP for reasons noted in para 4. DFIT has reviewed ECPs and has incorporated some of the recognized benefits into their physical fitness programs. To reduce the risk of injuries, DFIT has also developed a Tactical Athlete User Clinic, which educates and trains CF personnel on how to safely perform complex weight lifting techniques commonly found in ECPs (e.g., clean and squat). In addition, two courses (the Basic Fitness Training Assistant (BFTA) and the Advanced Fitness Training Assistant (AFTA)) are offered to CF personnel who are interested in leading safe and effective unit physical training. Local PSP fitness personnel are also available to provide information and guidance on safe training principles and other conditioning programs that incorporate accepted training doctrine.
Based on the results of this initial investigation, it is recommended that patients presenting with muscle pain and/or weakness, swelling, limited range of motion or tea coloured urine be asked about the type, amount and start date of any recent strenuous physical activity including engaging in ECPs, such as CrossFit®. In patients presenting without the cardinal sign of tea coloured urine, a differential diagnosis of ER should still be considered if they have a history of recent intense physical activity (including CrossFit®), especially in patients reporting a sudden increase in activity. Appropriate diagnostic blood work, including serum CK, should be drawn. (reference C and D).
It is recommended that patients be counselled regarding the dangers of ECPs and that they are informed of mitigating factors that can help prevent ER (e.g., gradual training progression, adequate hydration, appropriate rest periods, factoring in the effects of heat and humidity, and individualized training) for preventing ER. Patients should also be referred to their local PSP fitness personnel for guidance on safe and effective fitness training. (reference B, E and F)
CF Health Services Group will continue to gather more detailed information on current ER cases. New cases should be reported to D FHP by email at +DFHP Iinquiries@CMP DGHS@Ottawa-hull.
Enquiries related to this advisory should be directed to D FHP as follows:
a. e-mail: +DFHP Inquiries@CMP DGHS@Ottawa-hull
b. telephone: 613-945-6607
A. Hill OT, Wahi MM, Carter R 3rd, Kay AB, McKinnon CJ, Wallace RF. Rhabdomyolysis in the US active duty army, 2004-2006. Med Sci Sports Exerc. 2012. 44(3):442-9.
B. Bergeron MP, Bradley CN, Deuster PA, Baumgartner N, Kane SF, Kraemer WJ et al. Consortium for health and military performance and American College of Sports Medicine consensus paper on extreme conditioning programs in military personnel. Current Sports Medicine Reports. 2011. 10:383-89.
C. Khan FY. Rhabdomyolysis: a review of the literature. Neth J Med. 2009;67:272-83.
D. Huerta-Alardin AL, Varon J, Marik PE. Bench-to-bedside review : rhabdomyolysis – an overview for clinicians. Crit Care. 2005.9;158-69.
E. U.S. Army Public Health Command. What army leaders should know about extreme conditioning programs. PHN No: 0312-01 http://phc.amedd.army.mil/PHC%20Resourc ... y_2012.pdf
F. USU Consortium for Health and Military Performance, Human Performance Resource Center, Uniformed Services University of Health Services, and American College of Sports Medicine. April 2011. CHAMP/ACSM executive summary: High-intensity training workshop. http://hprc-online.org/files/hit-executive-summary