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N O P AIN, N O G AIN : A W ORKOUT G ONE A WRY Herbie Yung MD 1 Lindsey Kowalski DO 2 Eric Anish MD 2 1 University of Pittsburgh Medical Center Department.

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Presentation on theme: "N O P AIN, N O G AIN : A W ORKOUT G ONE A WRY Herbie Yung MD 1 Lindsey Kowalski DO 2 Eric Anish MD 2 1 University of Pittsburgh Medical Center Department."— Presentation transcript:

1 N O P AIN, N O G AIN : A W ORKOUT G ONE A WRY Herbie Yung MD 1 Lindsey Kowalski DO 2 Eric Anish MD 2 1 University of Pittsburgh Medical Center Department of Physical Medicine and Rehabilitation 2 University of Pittsburgh Medical Center Department of Internal Medicine

2 I have no financial disclosures or conflicts of interest

3 P ATIENT 1 25 year old female with no medical history presenting to the hospital 3 days after a personal training session as a new client at a local fitness center with complaints of muscle aches and cola colored urine Her self reported exercise regimen is about 40 minutes of cardio followed by 20 minutes of weight lifting 5 days a week On exam she had diffuse tenderness to palpation in her back, arms, chest, but most tender in bilateral thighs with mild edema. Distal lower extremity pulses intact

4 P ATIENT 1 Her workout session that day included: 8 sets of 20 squats with dumbbells with 30 seconds of rest 5 sets of 30 pushups Lunges with dumbbells Deadlifts with dumbbells Core exercises Her entire session lasted between 1 to 1.5 hours

5 P ATIENT 2 20 year old male with a past medical history of pyloric stenosis presenting to the hospital 2 days after a personal training session as a new client with the same trainer at the same fitness center with complaints of thigh tightness, cramping and cola colored urine His self reported exercise regimen is college recreational sports and weight lifting On exam he had tenderness to palpation in bilateral thighs and calves. Full range of motion in lower extremities.

6 P ATIENT 2 His workout session that day included : 8 sets of 20 squats with the trainer providing resistance on his shoulders 5 sets of pushups After the set of pushups he was unable to continue as his legs “locked up.” The trainer told him to walk on the treadmill for the next 45 minutes His entire session lasted about 1 hour

7 P ATIENT 3 35 year old male with no medical history presenting to the hospital 3 days after a personal training session as a new client with the same trainer at the same fitness center with complaints of bilateral thigh pain, leg cramps and brown urine. He reports he hasn’t been active for the past 6 months and was hoping to get in shape, but did play recreational soccer in the past On exam he had tenderness to palpation in bilateral thighs, decreased range of motion in the hips and knees. Distal lower extremity pulses intact

8 P ATIENT 3 His workout session that day included: 100 squats 70 pushups Medicine ball toss sit ups After the sit ups, he was unable to continue due to nausea and lightheadedness Of note, he reports having 5 alcoholic drinks the night prior to his session His entire session lasted about 25 minutes

9 L ABORATORY D ATA Patient 1: 25 yo FPatient 2: 20 yo MPatient 3: 35 yo M CPK 77,386CPK: 109,300CPK: 65,904 ALT/AST : 383/972ALT/AST: 393/1794ALT/AST 323/1667 UA: dark yellow urine, 2+ blood, 2+ protein, no cells UA: yellow urine, 3+ blood, 1+ protein, no cells UA: yellow urine, 3+ blood, trace protein, no cells Aldolase: 317

10 D IFFERENTIAL D IAGNOSES Exertional Rhabdomyolysis Infectious Rhabdomyolysis Drug Induced Rhabdomyolysis Delayed Onset Muscle Soreness Compartment Syndrome Metabolic Myopathies Dystrophinopathy Sickle Cell Anemia/Trait

11 D IAGNOSIS Exertional Rhabdomyolysis Myalgias, edema, weakness CPK greater than 5 time upper limit of normal Myoglobinuria Elevated creatinine

12 H OSPITAL C OURSE Patient 1: 25 yo FPatient 2: 20 yo MPatient 3: 35 yo M Given 0.9% normal saline, electrolytes, I/O monitored daily Given lactated ringers, electrolytes, I/O monitored daily Discharged on hospital day 5 Discharged on hospital day 3 CPK 10,708 (77k on admission) CPK 7,693 (109k on admission CPK 21,187 (65k on admission) Follow up CPK of 1,160 3 days later (day 8) Follow up CPK of 1,181 3 days later (day 6)

13 R ISK S TRATIFICATION Low RiskHigh Risk Rapid recovery with normalization of CPK level Delayed recovery (>1 week) Physically fit athlete with history of vigorous workouts Muscle injury after low or moderate work No personal or family history of rhabdomyolysis, severe muscle cramps, weakness or heat stroke Personal or family history of malignant hyperthermia, sickle cell Other people in same group or team with related cases of ER during the same session Exertional rhabdomyolysis complicated by acute renal failure Documented consumption of drug/dietary supplement known to exacerbate ER (caffeine, amphetamines, ephedra Reoccurence or family history of exertional rhabdomyolysis or severe muscle cramping interfering with ADLs Documented infectious illnessPersistently elevated CPK (>5x normal for 2 weeks) Peak CPK >100,000

14 R ETURN TO P LAY Phase 1 Follow up with provider in 72 hour for repeat CPK and UA Progress when CPK is less than 5X normal Phase 2 Begin light activities at own pace and distance Follow up with provider in 1 week Progress when there is no weakness, soreness, swelling or pain Phase 3 Gradual return to sporting activities and physical training Follow up with provider as needed

15 C ONCLUSION Given the size and popularity of this fitness center, this could be a potential health concern as 3 patients presented within a 1 week period A phone call was made to the fitness center to alert them of the 3 hospitalizations The manager reported this workout was a new fitness evaluation tool implemented by their newly hired director of personal training for new clients A phone call was also made to the Director of the Allegheny County Health Department who then visited the fitness center

16 Thank you! Questions?

17 R EFERENCES 1. Bosch X, Poch E, Grau JM. Rhabdomyolysis and Acute Kidney Injury. New England Journal of Medicine. Jul ; 361 (1): Wise JJ, Fortin PT. Bilateral, Exercise-Induced Thigh Compartment Syndrome Diagnosed as Exertional Rhabdomyolysis. American Journal of Sports Medicine. 1997; 25 (1): Woodrow G, Brownjohn AM, Turney JH. The clinical and bicohemical features of acute renal failure due to rhabdomyolysis. Ren Fail. 1995; 17: Casa DJ et al. The Inter-Association Task Force for Preventing Sudden Death in College Conditioning Sessions: Best Practices Recommendations. Journal of Athletic Training. Aug 2012; 47 (4): O’Connor et al. Return to Physical Activity After Exertional Rhabdomyolysis. American College of Sports Medicine (6):


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