Health issue 2014: High intensity workouts, rhabdo, and what you should know

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At CrossFit Charlottesville, trainers are taught to recognize the symptoms of rhabdomyolysis, said gym co-owner Kyle Redinger. Photo: Elli Williams At CrossFit Charlottesville, trainers are taught to recognize the symptoms of rhabdomyolysis, said gym co-owner Kyle Redinger. Photo: Elli Williams

This story is part of our 2014 health issue, which also includes articles on mammography, concussions in young athletes, and gluten intolerance.

Anyone who’s begun a new exercise program knows muscle soreness is possible, but that it’s usually gone after a couple of days of moaning and groaning when you move. Three days after she’d tried a high intensity interval training workout for the first time last summer, Meri Jane Smith’s pain was getting worse, and her arms were swelling like sausages.

“I couldn’t even lift them,” recalled Smith, a 34-year-old Downtown mother of two and longtime exerciser who’d been hoping to add weight lifting to her regular routine of running, yoga, and tennis.

“It was a new horizon,” she said. “My goal was to start building muscle after years of cardio.”

Four days after the workout—which incorporated three sets of 12 push-ups, 12 standing push-ups, 12 bicep curls and “planks,” in which a person holds herself parallel to the ground resting only on her forearms and toes—her pain, arm swelling, and general fatigue was still increasing. Smith started Googling, and discovered her symptoms matched an exercise-induced ailment that, if left untreated, can be fatal: Rhabdomyolysis.

The condition occurs when muscle cells are damaged through exercise or injury, causing release into the blood of a protein known as myoglobin and a substance called creatine kinase, commonly referred to as CK. If the levels of these substances are sufficiently high, kidney damage and even failure can occur, as can cardiac arrest. With high intensity workouts soaring in popularity, it’s a hot topic in exercise obsessed Charlottesville.

Convinced she was suffering from “rhabdo,” Smith drove herself to the emergency room at Martha Jefferson Hospital, where she said her self-diagnosis was initially met with doubt after she told a nurse she didn’t have one of rhabdo’s signature symptoms: cola-colored urine, which results from the elevated myoglobin.

“I think they thought I was a soccer mom who was seeking pain meds,” she said. After waiting several hours to receive treatment, and with a sitter at home who needed to leave, Smith grew frustrated and left the ER, but scheduled an appointment with a doctor first thing in the morning. He agreed with her self-diagnosis and sent her back to the hospital for blood testing, which confirmed it.

“They said, ‘Your CK levels are at 25,000 units per liter,’” Smith recalled, more than 100 times the normal CK level for a woman in her 30s. She was placed on an IV immediately and admitted to the hospital where she spent the next 72 hours as doctors waited for her levels to drop.

“They were pounding me full of fluids,” said Smith, who described her heart rate periodically dropping as her body worked to flush the toxins. It took about two weeks after she was released for the final swelling in her arms to disappear and her normal energy level to return.

It’s not common to see rhabdomyolysis in women, said UVA toxicologist Chris Holstege, who has treated dozens of rhabdo cases associated with crush injuries and also self-inflicted through exercise. Most of those suffering from the exercise-induced version of the disorder are men who have overdone it lifting heavy leg weights with high repetitions.

“The worst cases I’ll see are in prisoners who are doing repetitive squats competing with each other,” said Holstege. And while high intensity interval exercising has soared in popularity over the past several years in this area, with two CrossFit affiliates and numerous other gyms offering boot camp style classes, Holstege said he hasn’t seen the number of rhabdo cases climb significantly. That, he said, is because most of the time the body can handle flushing the toxins out, even if a workout has been overly intense. Hydration is key.

“Most people are going to do fine even if [CK] levels go up a little bit,” he said, urging exercisers to increase fluid intake before, during and after workouts to aid in the flushing out process.

While high intensity exercise newbies like Smith should ease into a rigorous workout routine, Kyle Redinger, co-owner of CrossFit Charlottesville, says formerly serious athletes who are returning to working out seem to be the most at risk for rhabdo since they remember what they used to be able to do and  may try to match their former level too quickly.

“A lot of people are mentally stronger than their body,” said Redinger, noting that he’s aware of only one other rhabdo-related hospitalization in Charlottesville, and adding that the most important thing is for people to “listen to your body.”

Smith agrees, and believes her condition was a type of “perfect storm.”

She tried the high intensity workout on a blazingly hot July day in a garage space with no air conditioning, and she’d joined in with an experienced group.

“Peer pressure took over my natural self-limiting capacity,” said Smith, who admits to a competitive streak. “I didn’t stop when it was hurting me.”

Making matters worse, said Smith, she didn’t drink enough in the days that followed, and, without knowing it, committed the final rhabdo no-no: taking Advil, which Holstege said decreases urine output and therefore allows the harmful muscle toxins to build even further in the blood.

“If you’re at a point where your kidneys are getting damaged, you don’t want any anti-inflammatories,” he said.

Smith said her rhabdo experience hasn’t put her off weight training—she’s working out at her own pace again, and she’s back to focusing on the exercises she’s done all along, adding in a few lighter weight training sessions each week.

The biggest lesson learned, she said: “Don’t let anyone else be the voice in your head.”

Correction: The original version of this article gave an incorrect age for Meri Jane Smith. She is 34.

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