ACUTE EXERTIONAL RHABDOMYOLYSIS

Acute Exertional Rhabdomyolysis (AER) is a risk, when Athletes are conditioning and training. Coaches and Athlete have a tendency to be over-the-top, supersize and overuse exercises. Work-outs during off-season are particularly dangerous for acute exertional rhabdomyolysis. Moderation must be the rule when continued during the season. Overzealous strength Coaches and Athletes must be careful.

Acute Exertional Rhabdomyolysis is a medical diagnosis for rapid damage of skeletal muscle tissue during acute over-exertion. When the damaged muscle products are released into the blood circulation, the protein myoglobin and other products can be harmful to the kidneys and may lead to kidney failure.

The damaged muscles can swell and cause Compartment Syndrome when the fascial tissue compartments restrict swollen muscles within their confined fascial spaces from further swelling. Compartment Syndrome can cause further necrosis from ischemia, lack of blood supply.

The symptoms might include muscle pains, vomiting and confusion, depending on the extent of muscle damage, muscle pathological products in the blood and kidney failure develop.

Medications, drugs, infections, extreme ambient heat and humidity can exacerbate Acute Exertional Rhabdomyolysis during extreme exertion.

Acute Exertional Rhabdomyolysis is suggested by the history of recent and past events and the physical examination such as over-exercise in extreme environments. It is confirmed by blood and urine testing. An important part of diagnosing rhabdomyolysis is a comprehensive medical history and physical examination.

The diagnosis of rhabdomyolysis is confirmed by detecting elevated muscle enzymes in blood. Muscle enzymes include creatine phosphokinase (CPK), SGOT, SGPT, and LDH. The levels of these enzymes rise as the muscle is destroyed in rhabdomyolysis.

Of note, CPK is also in heart muscle (cardiac muscle) and brain. Laboratories are usually able to distinguish between the different components of this enzyme. For example, the fraction coming from skeletal muscle is referred to as CK-MM and the one from heart muscle is designated as CK-MB. There are small amounts of the CK-MB component in the skeletal muscle as well.

The levels of myoglobin can be elevated in blood and urine.

SGOT: Serum glutamic oxaloacetic transaminase, an enzyme that is normally present in liver and heart cells. SGOT is released into blood when the liver or heart is damaged. The blood SGOT levels are thus elevated with liver damage (for example, from viral hepatitis) or with an insult to the heart (for example, from a heart attack). Some medications can also raise SGOT levels. SGOT is also called aspartate aminotransferase (AST).

SGPT: Serum glutamic pyruvic transaminase is an enzyme that is normally present in liver and heart cells. SGPT is released into blood when the liver or heart is damaged. The blood SGPT levels are thus elevated with liver damage (for example, from viral hepatitis) or with an insult to the heart (for example, from a heart attack). Some medications can also raise SGPT levels. Also called alanine aminotransferase (ALT).

General treatment is intravenous fluids. Renal dialysis might become necessary if renal impairment results. Surgical decompression of the fascial compartments might be required.
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The following are reports and references for AER. The first report is the most excellent published response and investigation to an Acute Exertional Rhabdomyolysis Epidemic. This excellent investigation was conducted by Dr. Katrina Hedberg, MD, MPH.

Heat, Dehydration Factors In McMinnville Injuries, 1st POSTED: 11:54 am PDT September 2, 2010 http://www.oregon.gov/DHS/ph/ipe/docs/OPHD_Football_Prelim_Report.pdf

PORTLAND, Ore. — State health officials investigating muscle injuries suffered by 24 members of the McMinnville High School football team said intense exercise, heat and dehydration were factors in the illness, while tests for chemical supplements came back inconclusive.

“There is not one factor that we can pinpoint as the cause. Rather, it appears that multiple factors including the type of exercise, the hot day and not enough water for some of the players contributed to their illnesses,” said Katrina Hedberg, Oregon state epidemiologist.

The injuries stemmed from a preseason workout on Aug. 15 with the team’s new coach, Jeff Kearin, in a hot wrestling room.

Of the 43 football players participating in the camp, three needed surgery for compartment syndrome, a type of painful muscle swelling.

Five others suffered from rhabdomyolysis, a muscle injury that can lead to kidney failure, in addition to elevated muscle enzymes signifying injury. Fourteen additional players had muscle pain with and elevated enzyme levels, health officials said.

The hospitalized players denied taking supplements that could have contributed to the injuries. Oregon Department of Human Services officials said blood tests for creatine levels were inconclusive because the tests don’t discern between supplemental creatine and naturally occurring levels.

The last player was released from the hospital Aug. 24.

An inspection of the McMinnville High School gym and wrestling room didn’t reveal any problems with water quality, carbon monoxide or other problems that could have sparked the injuries.

Food-borne illnesses were also ruled out as possible factors, health officials said.

A team of several epidemiologists began the investigation Aug. 23. They recommended coaches and school officials keep in mind that intense, repetitive exercise focusing on single muscle groups can cause injury. They also said coaches need to constantly assess players’ health and adjust workouts accordingly.

Despite the injuries, McMinnville High School will start its football season on schedule with a game against Sam Barlow High School at 7 p.m. Friday in Gresham.

Preliminary Report:

Cluster of Compartment Syndrome and Rhabdomyolysis Among McMinnville High School Football Team
Katrina Hedberg, MD, MPH
State Epidemiologist
Oregon Public Health Division
2 September 2010 2

Summary

“On 23 Aug 2010, the Oregon Public Health Division (OPHD), in coordination with Yamhill County Health Department, began investigating a cluster of triceps compartment syndrome and rhabdomyolysis among McMinnville High School football team members with onset of illness during the previous week.

“Compartment syndrome, typically resulting from muscle injury, is characterized by abnormally high pressures in an enclosed muscle compartment that impedes adequate blood circulation; it is a surgical emergency.

‘Rhabdomyolysis is muscle injury that can lead to kidney failure and death.) OPHD investigated this cluster in order to: 1) confirm the diagnoses and spectrum of illnesses; 2) identify contributing factors leading to illnesses; 3) derive information to help ensure the safety of participants in organized sports and prevent similar illnesses from recurring. Oregon Administrative Rule 333-018-0015 authorizes OPHD to conduct public health investigations of any “uncommon illness of potential public health significance”. This preliminary report summarizes the OPHD investigation as of 2 Sep 2010.

OPHD conducted interviews with team members, coaches, school administrators, hospital administrators, and physicians; and reviewed the hospital medical records for all team members cared for at Willamette Valley Medical Center (WVMC).

OPHD also systematically assessed symptoms, exposures, and activities among team members. Following several hospitalizations of team members from 17-19 Aug 2010, WVMC offered creatine kinase (CK) testing (a blood test marker of muscle injury) of all team members on 19-20 Aug 2010 at McMinnville High School.

Among 43 team members participating in the varsity “immersion” football camp held the week 15 Aug 2010, 3 had triceps compartment syndrome, defined as a team member clinically diagnosed with this condition and treated with surgery, an additional 5 had rhabdomyolysis with muscle pain and CK > 23,200 U/L (100 times the upper limit of normal for WVMC laboratory), and 14 others had rhabdomyolysis with muscle pain and CK between 2,320 U/L (10 times the upper limit of normal) and 23,200 U/L. Of the 22 team members with triceps compartment syndrome and/or rhabdomyolysis, all 3 had muscle-related symptoms referable to the upper arm, 12 were hospitalized, and none had kidney failure. CK testing at McMinnville High School identified 16 of the 22 cases.

OPHD reviewed an upper arm exercise held on 15 Aug 2010 at approximately 1600 PDT in the high school wrestling room. The “team building” exercise involved repetitive, intensive, alternating chair dips and push ups for an estimated 4-5 minutes. It had been used by the head coach with previous teams dating back to 2003 without incident. Team members characterized this exercise as challenging but within the boundaries of pre-season conditioning. The temperature in the non-air conditioned wrestling room was not measured at the time of the exercise drill; however, the temperature recorded at McMinnville Municipal Airport at 1553 PDT was 92°F. While water was available and coaches encouraged consumption during the camp, most team members did not consume water during the exercises in the wrestling room.

Team members did not report use of illicit or performance enhancing drugs. Serum creatine levels, which do not distinguish creatine supplementation from dietary or endogenous creatine, were inconclusive. On preliminary review, OPHD did not find patterns suggesting an association with illness from specific prescription medications or nutritional supplements. Facilities assessment did not find any evidence that other environmental factors, including water quality, carbon monoxide, or volatile organic compounds, contributed to the illnesses. There was no evidence that infections or contaminated food or drinks were associated with illness.

OPHD concluded that multiple factors likely contributed to the cluster of triceps compartment syndrome and rhabdomyolysis, foremost among them an intense, short-duration, repetitive burst of resistance exercise on Sun 15 Aug 2010 that focused on a single muscle compartment. Additional contributing factors included environmental stress from heat and unrecognized dehydration.

‘Based on this preliminary report, OPHD recommends that: 4

1. Oregon coaches, trainers, school administrators, health professionals, parents, and recreational athletes recognize that intense, short-duration, repetitive resistance exercise involving a single muscle compartment can lead to serious health complications, particularly during exercise conditions with higher risk of heat stress and inadequate hydration.

2. Both during and outside of official sports seasons, Oregon coaches, trainers, and school administrators routinely and explicitly assess potential health and safety hazards to student-athletes, and implement appropriate countermeasures as warranted, such as activity modification, rest breaks, and hydration.’ 5

Background

‘On Monday, 23 Aug 2010, in coordination with Yamhill County Health Department, OPHD began investigation of a cluster of triceps compartment syndrome and rhabdomyolysis among McMinnville High School football team members with onset of illness the previous week.

‘OPHD investigated this cluster in order to:

1) confirm the diagnoses and spectrum of illnesses,
2) identify contributing factors leading to illnesses,
3) derive information to help ensure the safety of participants in organized sports and prevent similar illnesses from recurring.

‘Oregon Administrative Rule 333-018-0015 authorizes OPHD to conduct public health investigations of any “uncommon illness of potential public health significance”.
This preliminary report summarizes the OPHD investigation as of 2 Sep 2010.

OPHD Investigational Methods

The OPHD field investigative team visited WVMC and/or McMinnville High School on 23, 24, 27, and 29 Aug 2010. An OPHD industrial hygienist augmented the team on a site visit of the school facilities on 27 Aug 2010, and recorded real-time measurements of carbon monoxide, carbon dioxide, and volatile organic compounds (VOCs).

OPHD reviewed the hospital medical records for all football team members who were hospitalized and/or seen in the emergency department, focusing on physician notes, laboratory results, and clinical outcomes. In addition, OPHD reviewed the CK results for all team members who underwent testing on 19-20 Aug 2010. OPHD held phone or in-person interviews with selected physicians involved in care of the team members, including the two orthopedists who performed the operations and the hospitalist/football team physician involved in the inpatient management of many of the hospitalized 6 team members. At least 7 WVMC medical staff contributed to admission or emergency department examinations.

Meetings and interviews were held with WVMC administrators, McMinnville School District superintendent, high school principal, athletic director, facilities director, football coaching staff, and team members. OSAA provided information on heat index rules. OPHD was also invited to a football parents meeting on 24 Aug 2010 that involved a question-and-answer session with three Oregon physicians from outside Yamhill County with expertise in sports medicine and nutrition. During and after this meeting, OPHD addressed team member parents’ questions and concerns.

OPHD developed a standardized questionnaire that systematically assessed symptoms, exposures, and activities; attempts were made to interview all team members by phone or in person. Phone interviews with student-athletes commenced 26 Aug 2010. To increase the number of respondents, with the permission of the head coach, two OPHD epidemiologists conducted in-person interviews concurrent with team film study on 29 Aug 2010. All interviews were conducted privately.

Student-athletes and parents were instructed that individual responses were confidential, non-attributional, and not reportable to school, parental, and legal authorities. As of 2 Sep 2010, questionnaires were completed by 40 of 43 team members.

Summary of Events at McMinnville High School Football Camp – Sun 15 Aug 2010 – Fri 20 Aug 2010

Source: Interviews with coaching staff and team members; temperature data at McMinnville from National Weather Service (McMinnville Municipal Airport, elev. 157 ft.)

Sun 15 Aug 2010 – Beginning of football “immersion” camp at McMinnville High School. The overnight camp was restricted to 10th, 11th, and 12th grade football team members. After the team dropped off personal items in White Gymnasium (sleeping quarters for the camp), team members warmed up on the football field and completed several timed sprints. At approximately 1600 PDT, the team moved to the 7 indoor wrestling room to perform an exercise drill that the head coach had used numerous times with previous teams. The intent of the drill, as described by the head coach, was primarily to build team unity and accountability to other team members.

None of the assistant coaches had prior experience with this drill. Team members voluntarily picked partners for the exercise drill. The first exercise was described as a chair dip/push up exercise. The first partner, with second partner spotting, performed chair dips using the folding chair as support for 30 seconds, immediately followed by pushups for 30 seconds. This sequence was repeated in consecutively shorter intervals: 20 seconds, 10 seconds, 7 seconds, 5 seconds, with no scheduled rest periods. For incorrect performance by any team member, the exercise was suspended and then re-started by all team members at the beginning of the exercise component and time interval that team members had been engaged in at the time of suspension. The spotting partner was responsible for providing support for muscle fatigue and assist in both the concentric and eccentric phases of muscle contraction.

The targeted muscles during the drill were the triceps, pectoralis major, and deltoids. After the first group completed the exercise, the roles were switched. The exercise, without transition time, lasts 144 seconds. The actual estimated time for one partner to complete the exercise, including transition time and repeated interval times, was approximately 4-5 minutes. The second exercise focused on abdominal and leg muscles, and incorporated a similar timed format. The total amount of time in the wrestling room was estimated as 20-25 minutes. Team members characterized the arm exercise as challenging but within the boundaries of pre-season conditioning.

Water was available and consumption encouraged by coaches throughout the camp, but most team members did not consume water while they were in the wrestling room. The temperature in the non-air conditioned wrestling room that day was not available; the temperature in McMinnville at 1553 PDT was 92°F. Team members slept at home. High/Low temperature: 94°F/53°F. 8

Mon 16 Aug 2010 – 2nd day of football camp. Practices were held throughout the day, with conditioning work in the form of sprints held in the evening. Team members began to sleep at the high school gymnasium that night. High/Low temperature: 94°F/54°F.

Tue 17 Aug 2010 – An assistant coach transported a team member with arm pain and swelling to a physician appointment. The first case of compartment syndrome was diagnosed. A light weightlifting session was held in the morning. Practices were again held throughout the day. No conditioning drills were reported. High/Low temperature: 88°F/57°F.

Wed 18 Aug 2010 – Five more team members were hospitalized, including 2 additional cases of compartment syndrome. In the evening, the remainder of team was briefly screened for compartment syndrome at the high school by one of the treating WVMC orthopedists. No additional suspect compartment syndrome was identified. High/Low temperature: 76°F/50°F.

Thu 19 Aug 2010 – No outdoor or indoor exercise drills were held. WVMC sponsored voluntary CK testing of all team members in the evening; 28 team members underwent testing.

Fri 20 Aug 2010 – An additional 6 team members and 5 coaches underwent CK testing. Parents were notified of CK results. Team members with CK > 3000 U/L were advised to seek emergency care at WVMC. This led to 6 additional hospitalizations, and 10 other team members seen in the WVMC emergency department only. Football camp closed on 20 Aug 2010, one day prior to scheduled conclusion.

Findings of OPHD Investigation:

Description of Cases:

Among 43 team members participating in the varsity “immersion” football camp held the week 15 Aug 2010, 3 had triceps compartment syndrome, 5 others had rhabdomyolysis with CK > 23,200 U/L (100 times the upper limit of normal for WVMC laboratory), and 14 others had rhabdomyolysis with CK 9 betweeen 2,320 U/L (10 times the upper limit of normal) and 23,200 U/L. Of the 22 team members with triceps compartment syndrome and/or rhabdomyolysis, all had muscle-related symptoms referable to the upper arm, 12 were hospitalized, and none had kidney failure. CK testing at McMinnville High School identified 16 of the 22 cases.

Toxicology data:

Team members did not report use of illicit or performance enhancing drugs. Urine toxicology testing was not done during hospitalization and emergency department evaluation. Serum creatine levels, which do not distinguish creatine supplementation from dietary or endogenous creatine, were inconclusive. On preliminary review, OPHD did not find patterns suggesting an association with illness from specific prescription medications or nutritional supplements.

Potential environmental sources of illness:

OPHD investigated school facilities, including the gymnasium, wrestling room, football field, school locker room, cafeteria, and food court. Several persons questioned whether environmental factors may have contributed to illness, including water, sewer work, mold, and floor finishing products. An OPHD industrial hygienist accompanied the investigative team on 27 Aug 2010 (high temperature that day was 76°F) and toured the facilities. Real-time measurements were taken for carbon monoxide, carbon dioxide, and volatile organic compounds (VOCs). VOC samples addressed concerns that White gymnasium had an offensive chemical smell attributed to recent refinishing. All VOC samples were non-detectable. In addition, there was no source of VOCs identified. There was no carbon monoxide present in any area.

Carbon dioxide (CO2) samples were taken as a surrogate indicator of adequate ventilation; excessive CO2 levels can indicate a lack of fresh air. All CO2 levels were below 400 ppm, including background levels that were taken outside. The OPHD investigators noted that the wrestling room seemed less ventilated than other indoor areas visited.

Other causes of rhabdomyolysis: 10

Through medical record review and interviews, OPHD did not find trauma, genetic defects, infections, and metabolic or electrolyte derangements contributed to this cluster of rhabdomyolysis.

Other findings of significance:

Compliance with OSAA rules pertaining to heat index calculation, recordkeeping, and practice restrictions was not mandatory during the football immersion camp. These rules were enforceable to OSAA member schools beginning on 23 Aug 2010, the first official day of high school football practice. Prior to 23 Aug 2010, McMinnville High School athletics did not record the heat index, which is typically done by a school athletic trainer during the official season.

The heat index on 15 Aug 2010, based on conditions at 1553 PDT (temperature of 92°F, dew point of 59°F, relative humidity of 33%) was 91°F. For heat index < 95°F, OSAA recommendations include: “maximum of 5 hours of practice today, provide ample amounts of water, water should always be available and athletes should be able take in as much water as they desire, watch/monitor athletes for necessary action.” The short duration of team exercises that day, comprising two timed sprints on the football field followed by the resistance exercises in the wrestling room, were not considered high operational risk for heat-related illness. No specific safety briefings on Sun 15 Aug 2010 addressing heat were reported by the coaching staff. Discussion Compartment syndrome and rhabdomyolysis both result from muscle injury. Trauma and exertion are known precipitants of these conditions. Upper arm acute compartment syndrome is extremely rare, however, and its occurrence following exertion is novel. In contrast, rhabdomyolysis secondary to exertion and/or heat-related illness has been well described in the medical literature, especially in athletes and military recruits. Eccentrically based activities, performed while the muscle elongates while under tension (“negatives”), pose a particular risk for rhabdomyolysis. 11 Although the CK threshold for diagnosing rhabdomyolysis has been proposed as 5-10 times the upper limit of normal, conditioned athletes who have had CK measured post-exertion in a non-clinical setting can have very high CK values. In one study of college football players in preseason practice, the average CK was 5,125 U/L, 30 times the norm for men. The CK testing on 19-20 Aug 2010 conducted at the high school likely contributed to case finding. OPHD was unable to determine how many of the 16 rhabdomyolysis cases who were first identified through this CK testing would have sought medical care in the absence of the testing. OPHD was unable to find any evidence that the cluster of compartment syndrome and rhabdomyolysis resulted from a primary cause that was not exertion-related. OPHD concluded that multiple factors likely contributed to the cluster of triceps compartment syndrome and rhabdomyolysis, foremost among them an intense, short-duration, repetitive burst of resistance exercise on Sun 15 Aug 2010 that primarily involved a single muscle compartment. Additional contributing factors likely included environmental stress from heat and unrecognized dehydration. Although compartment syndrome is distinct from rhabdomyolysis, OPHD concluded that similar factors contributed to both conditions; all three cases of compartment syndrome also had rhabdomyolysis. Although uncommon, prior case reports have also found rhabdomyolysis among conditioned athletes can result from similar intense, short-duration, repetitive resistance exercises focused on a single muscle compartment. OPHD reiterates that this report is preliminary; additional analyses are planned to better characterize this cluster of illness. Based on this preliminary report, OPHD recommends that: 1. Oregon coaches, trainers, school administrators, health professionals, parents, and recreational athletes recognize that intense, short-duration, repetitive resistance exercise involving a single 12 muscle compartment can lead to serious health complications, particularly during exercise conditions with higher risk of heat stress and inadequate hydration. 2. Both during and outside of official sports seasons, Oregon coaches, trainers, and school administrators routinely and explicitly assess potential health and safety hazards to student-athletes, and implement appropriate countermeasures as warranted, such as activity modification, rest breaks, and hydration __________________________________________ Acute Exertional Rhabdomyolysis is suggested by the history of recent and past events and the physical examination. It is confirmed by blood and urine testing. An important part of diagnosing rhabdomyolysis is a comprehensive medical history and physical examination. The medical history may include questions about any medication use, drug and alcohol use, other medical conditions, any trauma or accident, etc. Blood tests include a complete blood count (CBC), a metabolic panel, muscle enzymes, and urinalysis. The diagnosis of rhabdomyolysis is confirmed by detecting elevated muscle enzymes in blood. Muscle enzymes include creatine phosphokinase (CPK), SGOT, SGPT, and LDH. The levels of these enzymes rise as the muscle is destroyed in rhabdomyolysis. Of note, CPK is also in heart muscle (cardiac muscle) and brain. The laboratory is usually able to distinguish between the different components of this enzyme. For example, the fraction coming from skeletal muscle is referred to as CK-MM and the one from heart muscle is designated as CK-MB. There are small amounts of the CK-MB component in the skeletal muscle as well. The levels of myoglobin can be elevated in blood and urine SGOT: Serum glutamic oxaloacetic transaminase, an enzyme that is normally present in liver and heart cells. SGOT is released into blood when the liver or heart is damaged. The blood SGOT levels are thus elevated with liver damage (for example, from viral hepatitis) or with an insult to the heart (for example, from a heart attack). Some medications can also raise SGOT levels. SGOT is also called aspartate aminotransferase (AST). SGPT: Serum glutamic pyruvic transaminase, an enzyme that is normally present in liver and heart cells. SGPT is released into blood when the liver or heart are damaged. The blood SGPT levels are thus elevated with liver damage (for example, from viral hepatitis) or with an insult to the heart (for example, from a heart attack). Some medications can also raise SGPT levels. Also called alanine aminotransferase (ALT). ___________________________________________________________________ CDC October 26, 1990 / 39(42);751-756, Morbidity and Mortality Weekly Report Centers for Disease Control and Prevention, 1600 Clifton Rd, MailStop E-90, Atlanta, GA 30333, U.S.A Acute Exertional Rhabdomyolysis and Acute Renal Impairment -- New York City and Massachusetts, 1988 During the summer and fall of 1988, outbreaks of Acute Exertional Rhabdomyolysis (the breakdown of muscle fiber) with renal impairment occurred in New York and Massachusetts among candidates or trainees for public safety positions. In each of the outbreaks, risk for illness was lower in persons who were accustomed to vigorous exercise; however, incidence rates, the relation to dehydration, and settings differed.New York On June 14, 1988, the New York City (NYC) Department of Health was notified of one death and three hospitalizations among candidates for the NYC Fire Department (NYCFD) who had taken the NYCFD competitive physical fitness test within the previous 2 weeks. The fatality occurred in a young man with sickle cell trait who died because of uncontrollable hyperkalemia secondary to rhabdomyolysis within 6 hours of taking the fitness test; the three other hospitalized candidates had rhabdomyolysis and renal insufficiency. The firefighter physical fitness test is usually administered during a 2- to 3-month period every 4 years to approximately 25,000-30,000 men and women who are aged 19-29 years and who have passed the NYCFD written employment examination. The test, which was given indoors in a temperature-controlled environment, required the candidates to wear a 20-lb vest and a 20-lb oxygen tank while consecutively performing 11 activities that simulate typical firefighter tasks. Completion of the test in less than or equal to 7 minutes earned a passing score, and completion in less than or equal to 4 minutes earned a 100% score. Following the hospitalizations, the test was suspended on June 15 and resumed on June 27 with modified pre- and post-testing procedures. However, additional hospitalizations occurred, and on July 13, the test was again suspended. In late July, an epidemiologic investigation was initiated; the investigation included an environ mental evaluation for carbon monoxide, which did not reveal elevated levels inside the building. Testing was temporarily suspended four times during the 19 months (May 31, 1988-December 21, 1989) after it was initiated. Each suspension was followed by an evaluation of the test by medical experts and exercise physiologists. On June 27, a series of interventions was implemented to prevent exertional rhabdomyolysis by minimizing the effect of the ambient temperature, screening out candidates with current or prior medical problems, and assuring adequate hydration. Specific interventions included cancelling the test during the summer, requiring medical clearance from a physician, instructing candidates to reschedule the test if they were ill, urging candidates to avoid all medication and alcohol for 24 hours before and after the test, and providing fluids before the test. Despite these interventions, cases of rhabdomyolysis and/or renal impairment requiring hospitalization occurred during each of the five testing periods. During the 19-month period, 32 (0.2%) of 16,506 candidates were hospitalized for rhabdomyolysis and/or acute renal impairment after taking the fitness test; 41 other candidates were treated in emergency rooms but not admitted to hospitals. Of those hospitalized, four had rhabdomyolysis (defined as a serum creatinine phosphokinase (CPK) greater than or equal to 600 U/L (normal: 60-200 U/L)), and 16 had renal impairment (defined as serum creatinine greater than or equal to 3.0 mg divided by L (normal: 0.6-1.3 mg divided by L)); 12 had both rhabdomyolysis and renal impairment. Thirty (94%) of the 32 hospitalized candidates presented with back pain, 26 (81%) with nausea and vomiting, 20 (63%) with abdominal pain, 18 (56%) with muscle pain, and 18 (56%) with decreased urine output; four required hemodialysis. The mean hospital stay was 6 days (range: 1-20 days). All hospitalized candidates were men. None of the 84 women candidates reported illness. The mean age of the patients was 25 years; 29 were white, two were black, and one was Hispanic. After the second testing period, the NYC Department of Health and CDC conducted a case-control study using patients from the first two testing periods to assess potential risk factors. Thirteen of the 18 patients whose illnesses occurred in the first two periods agreed to be interviewed. Of the candidates who took the test during the same period and were not affected, 161 were selected randomly to serve as controls; 108 (67%) agreed to a telephone interview. The risk for rhabdomyolysis and/or acute renal impairment after taking the test was increased in candidates with an underlying medical condition (e.g., pneumonia or renal vein thrombosis) (odds ratio (OR)=10.3; 95% confidence interval (CI)=2.5-43.6). The risk was lower for men who engaged in physical activity (work plus leisure activity greater than or equal to 50 hours per week; OR=0.2; 95% CI=0.1-0.9). Risk for illness was not associated with the test score. Based on the epidemiologic and clinical data and the failure of the implemented interventions, the NYC Department of Health recommended that the test be modified before it is given again and a comprehensive survey be done of alternative methods of selecting firefighter candidates in other cities.Massachusetts On September 19, 1988, 50 police trainees from local police departments began a 14-week "mental stress" 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. The program was suspended, and an epidemiologic investigation initiated September 22 determined that some trainees had experienced severe dehydration, rhabdomyolysis, and/or acute renal insufficiency. An environmental investigation did not identify any biological agents in the air or water. All trainees were white; most were young adults (mean age: 25 years) and male (94%). The first 3 days of the training program were physically strenuous and included push-ups, squat-thrusts, and running. Daytime temperatures were 75-80 F (24-27 C), with a relative humidity of 50% (apparent temperature (heat index): 75-80 F (24-27 C)). During the training program, drinking water was available only during three or four short breaks each day; trainees obtained water from a 19-L (5-gal) water cooler using 90-mL (3-oz) fold-out cups and from faucets in the restrooms by hand scooping. The amount of water drunk by each trainee could not be quantified; however, based on the known limited availability of water, as well as reports of severe thirst and the large volumes of fluids drunk at the end of each day (compensatory hydration), water intake was considered to be grossly inadequate. All 50 trainees had evidence of rhabdomyolysis (serum CPK greater than or equal to 10 times normal) and 33 (66%) had severe rhabdomyolysis (serum CPK greater than or equal to 200 times normal). Thirteen (26%) 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%) of those hospitalized had evidence of renal insufficiency (serum creatinine greater than or equal to 2.0 mg divided by L); six (46%) required hemodialysis. One trainee died 44 days after onset from complications of heat stroke, rhabdomyolysis, and renal and hepatic failure. One month before the program, 49 of the trainees were tested for cardiovascular fitness (2.4-km (1.5-mile) run) and muscular strength (sit-ups). Compared with trainees who passed both tests, those who failed either test were at increased risk for severe rhabdomyolysis (relative risk (RR)=2.5; 95% CI=1.3-4.9) or renal insufficiency (RR=2.0; 95% CI=0.5-8.8). As a result of this investigation, the Massachusetts Criminal Justice Training Council extensively revised its police training program. "Mental stress" training, including the use of physical exercise as a punishment for infractions, was immediately abolished. An exercise physiologist who was appointed to develop a physical fitness regimen recommended requirements for 1) meeting specific physical fitness and medical standards before and during the training program; 2) adequate hydration during activity, based on the intensity and duration of the activity and prevailing environmental conditions; and 3) a clear administrative chain of responsibility and protocol for responding to injury or illness. Reported by: A Goodman, MD, S Klitzman, DrPH, S Lau, MPH, IW Surick, MD, S Schultz, MD, W Myers, MD, New York City Dept of Health. J Dawson, MD, Div of Critical Care, Bay State Medical Center, Springfield; JE Smith, Jr, Massachusetts Criminal Justice Training Council, RJ Timperi, MPH, GF Grady, MD, State Epidemiologist, Massachusetts Dept of Public Health. Div of Surveillance, Hazard Evaluation, and Field Studies, National Institute for Occupational Safety and Health; Div of Field Svcs, Epidemiology Program Office; Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note Editorial Note: Rhabdomyolysis is a natural consequence of vigorous physical activity. In persons unaccustomed to regular physical activity, rhabdomyolysis may be extensive, and renal impairment may occur, especially when dehydration or acidosis are also present (1). Dehydration alone can also cause impaired renal function by decreasing renal perfusion. These problems have been recognized among military personnel, long-distance runners, and other athletes (2-6). However, exercise-related rhabdomyolysis and renal impairment have not been previously described in the groups involved in this report. The circumstances in Massachusetts resemble those in military recruit training programs (i.e., young men of varying levels of physical fitness who begin sustained strenuous exercise in moderately warm outdoor conditions). In contrast, the outbreak in the NYC firefighter candidates was associated with an indoor temperature-controlled environment, and the exercise was brief (less than or equal to 7 minutes) in duration. Only one other outbreak of exertional rhabdomyolysis has been reported following a short exercise period ( less than 10 minutes) in an indoor setting (4). In Massachusetts, neither the ambient temperature nor humidity were markedly elevated (apparent temperature: 75-80 F (24-27 C)). Thus, the outbreak underscores the need to assure adequate hydration during exercise regardless of the temperature. Exercise physiologists recommend that, in addition to normal water replacement, an additional 250 mL of fluids is needed for every 15-20 minutes of exercise (7). Based on ambient dry bulb temperatures and relative humidity (Figure 1), nomograms have been developed to aid participants and persons responsible for groups involved in exercise during warm weather. Special efforts to assure hydration may be necessary when the apparent temperature approaches 80 F (27 C). The substantial difference in the hospitalization rates in NYC (0.2%) and Massachusetts (26%) probably reflects a variety of factors, including environmental conditions and types of exercise. In both outbreaks, however, level of physical fitness appeared to influence the risk for illness. High levels of physical fitness may be protective through increased muscle conditioning, accelerated heat acclimatization, and reduction of postexertional myoglobinemia (2,8-10). Thus, findings from both outbreaks support the general recommendation that persons who plan to engage in extreme muscle exertion should first participate in a preconditioning program to improve their physical fitness. Although the NYC investigation suggested that having an acute and/or chronic medical condition placed candidates at a higher risk for rhabdomyolysis and/or renal impairment, these findings should be interpreted with caution because case-patients may have been more likely than controls to report illness; consequently, their underlying conditions were more likely to be detected through medical record review. Certain conditions (e.g., viral illnesses, cocaine and aspirin abuse, and prior history of heat exhaustion) increase the risk for rhabdomyolysis and/or renal impairment (1,11). Sickle cell trait has been associated with an increased risk for sudden death during exertion (12). However, the absolute risk for sudden death is low, and persons with sickle cell trait should not be excluded, on that basis alone, from employment requiring maximal physical exertion (13). Based on this investigation and others (1,11), persons with infectious diseases should be advised to postpone testing until their illness has resolved; those with metabolic abnormalities should participate only with medical supervision; those with substance-abuse problems should be referred for appropriate treatment. In NYC, the increasing risk for illness despite successive implementation of preventive measures suggests that the effectiveness of case-finding improved and that severe rhabdomyolysis and renal impairment among participants in similar programs might occur more frequently than previously suspected. The increasing risk also suggests that the preventive measures could have been inadequate. Prior studies suggested that the measures were appropriate; however, those studies (1-7) were of persons engaged in exertion of much longer duration than the NYCFD candidates. The effect of measures to reduce or prevent exertional phenomena after short-duration activities needs to be clarified. In the United States, there are an estimated 800,000 police officers (14) and 203,000 paid and 500,000 volunteer firefighters (Federal Emergency Management Agency, National Fire Academy, unpublished data, 1989). Among these workers, fitness testing is used increasingly as a criterion for job entry and for job retention (International Association of Fire-Fighters, personal communication, 1989). The need for physical performance testing must be balanced carefully with the safety of persons participating in the testing; the National Fire Protection Association (NFPA) is developing new standards for fitness testing of firefighters. Physicians and other providers who monitor the health of these persons or who serve as occupational health consultants to fire and police departments, their unions, training academies, or advisory groups (e.g., the NFPA) should be aware of these potential problems. References 1. Gabow PA, Kaeny SP. The spectrum of rhabdomyolysis. Medicine 1982;61:141-52. 2. Demos MA, Gitin EL. Exertional myoglobinemia and acute rhabdomyolysis. Arch Intern Med 1974;134:669-73. 3. Schrier RW, Henderson HS, Tisher CC. Nephropathy associated with heat stress and exercise. Ann Intern Med 1967;317:356-76. 4. Hamilton RW, Gardner LB, Penn AS. Acute tubular necrosis caused by exercise-induced myoglobinuria. Ann Intern Med 1972;77:77-82. 5. Howenstine JA. Exertion-induced myoglobinuria and hemoglobinuria. JAMA 1960;173:493-9. 6. Demos MA, Gitin DL. The incidence of myoglobinuria and exertional rhabdomyolysis in marine recruits. Camp Lejeune, North Carolina: The Naval Medical Field Research Laboratory, 1973;23:1-5. 7. Costill DL. Gastric emptying of fluids during exercise. In: Gisolfi CV, Lamb DR, eds. Perspectives in exercise science and sports medicine. Vol 3. Fluid homeostasis during exercise. Carmel, Indiana: Benchmark Press, 1990:97-121. 8. Olerud JE, Homer LD, Carroll HW. Incidence of acute exertional rhabdomyolysis. Arch Intern Med 1976;136:692-7. 9. Gisolfi C, Robinson S. Relations between physical training, acclimatization, and heat tolerance. J Appl Physiol 1969;26:530-4. 10. Gavhed DC, Holmer I. Thermoregulatory responses of firemen to exercise in the heat. Eur J Appl Physiol 1989;59:115-22. 11. Roth D, Alarcon FJ, Fernandez JA, et al. Acute rhabdomyolysis associated with cocaine intoxication. N Engl J Med 1988;319:673-7. 12. Kark JA, Posey DM, Schumacher HR, Ruehle CJ. Sickle cell trait as a risk factor for sudden death in physical training. N Engl J Med 1987;317:781-7. 13. Sullivan LW. The risks of sickle cell trait: caution and common sense. N Engl J Med 1987;317:830-1.14. Bureau of Justice Statistics. Profile of state and local law enforcement agencies, 1987. Washington, DC: US Department of Justice, Bureau of Justice Statistics, 1989; publication no. NCJ-113949. _________________________________________________________________ [Multiple University of Oregon football players hospitalized after grueling workouts; by Andrew Greif | The Oregonian/OregonLive By Andrew Greif | The Oregonian/OregonLive, January 16, 2017 at 4:40 PM, updated January 16, 2017] "Multiple Oregon Ducks football players hospitalized after grueling workouts. At least three Oregon Ducks football players were hospitalized after enduring a series of grueling strength and conditioning workouts at UO last week, The Oregonian/OregonLive has learned." "3 football players are in fair condition and remained at Peace Health Sacred Heart Medical Center at Riverbend in Springfield on Monday, a hospital spokeswoman said. They have been in the hospital since late last week after workouts that occurred during the team's return from holiday break. " Poutasi's mother, Oloka, said that her son complained of very sore arms after the workouts and had been diagnosed with rhabdomyolysis. Oregon coach Willie Taggart visited Riverbend to meet with some of the hospitalized players before leaving the state to recruit. "Players this week were required to finish the same workouts, which were described by multiple sources as akin to military basic training, with one said to include up to an hour of continuous push-ups and up-downs. "Some players later complained of discolored urine, which is a common symptom of rhabdomyolysis. After testing, others were found to have highly elevated levels of creatine kinase, an indicator of the syndrome. "For the first time since 2004, Oregon did not qualify for a postseason bowl game in 2016. Oregon hired Irele Oderinde its new football strength and conditioning coach earlier this month. He followed Taggart from South Florida, where Oderinde had worked as the school's director of athletic performance since 2014. [Multiple University of Oregon football players hospitalized after grueling workouts; Andrew Greif | The Oregonian/OregonLive By Andrew Greif | The Oregonian/OregonLive, January 16, 2017 at 4:40 PM, updated January 16, 2017]

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