Rhabdo what? Overexertion can damage muscles, kidneys, and even kill.
Part one of a two part series on the effects of overexertion on training and arrest situations
A recent posting on the ASLET listserv under the subject line “Specialized NYPD Training Suspended After Officers
Fall Ill” reminded me of what my granddaddy used to say “too much of anything can kill you." Exercise is no
exception. The following is an excerpt from that posting:
New York, New York, United States (AP) - Police officials were still trying to determine Wednesday what
caused 12 officers taking a specialized training course to exhibit unusually high enzyme levels in their
blood…"consistent with muscle damage associated with intense exercise,"…. but they are focusing on intensive
exercise. Five remained hospitalized Wednesday…….the 12 officers began the three-to-five day training
"Uniformed Members of the Service Performing Enforcement Duties in Plainclothes" last Wednesday. The
course teaches self-defense and proper techniques in punching and kicking as well as how to disarm and
handcuff a suspect……..
Pretty weird huh? Well a similar situation to this was noted in the first column of the Trainers Safety Net and
referenced an incident that occurred in 1988. It was a warm September day, when 50 recruits began their first
day of training at the Police Academy in Agawam, Massachusetts. Over the course of that day, the cadets
performed numerous calisthenics, including sit-ups, push-ups, and jogging. Bottled water or a hose with running
water was provided to the cadets for drinking, but they may not have had easy access to this water. About 4:00
p.m. that afternoon during a run, a 25-year old cadet collapsed on the track. He was rushed to the hospital and
put on dialysis due to acute kidney failure. He died 41 days later. An additional 11 cadets were hospitalized,
with 6 requiring dialysis.18 ASLET member and past contributor, Martin Michelman has first hand knowledge of
this incident. He commented that this was a great example of why fitness standards and trained personnel must
be directly involved in those areas that involve intense physical activity. (if you have further questions contact
him at martin_michelman@scsdma.org)
The Massachusetts incident is not unique, another example of police academy disasters occurred in Oklahoma.
On the first day of an Oklahoma Highway Trooper academy in 1991, 39 cadets started with intense calisthenics
and runs. In addition the cadet “leader” performed approximately 1000 penalty push-ups. By the third day, the
“leader” and two of his classmates were hospitalized with rhabdomyolysis. The former Marine running this
program apparently achieved at least half of his goal to "break ‘em down, then build them up" since by the
seventh day only five of 35 cadets had normal enzyme levels in their blood.
Even before the academy experience, tragedy can strike. A brief but demanding entrance test for New York
City firefighters hospitalized 32 of 16,000 applicants with rhabdomyolysis and acute kidney failure, one of whom
died.18
These examples demonstrate that there is still a problem with excessive unfamiliar exercise in the world of
police training as well as other areas. This article will outline the, causes, characteristics, and consequences of
rhabdomyolysis in training and arrest situations.
1
The common denominator in these situations appears to be a syndrome known as exertional rhabdomyolysis.
Literally, the “rhabdo-” is from the Greek term meaning “rod or rod like” (in reference to the muscle cells), “myo-”
refers to muscle, and “lysis-” means to split or tear apart. Rhabdomyolysis then, is damage to the muscle cells
that is characterized by a group of conditions including muscle pain, tenderness, weakness, swelling, increased
levels of muscle components in the blood and urine after strenuous, overexertion or exercise. 37 Although the
incidence of severe rhabdomyolysis is rather low, this condition can be dangerous and even fatal.
Myoglobin in the urine – if its brown more water must go down
One of the proteins released from damaged muscle cells is myoglobin. Myoglobin is a compound similar to its
better-known relative, hemoglobin. Like hemoglobin, myoglobin is an oxygen binding protein and is found
almost exclusively in muscle tissue. Myoglobin is not normally found in urine. High levels of myoglobin in the
blood result from a "spill over" of myoglobin into the urine also known as myoglobinuria. In myoglobinuria the
urine can exhibit a color range from light "iced-tea" to "Coca-Cola." In certain situations, myoglobin can gather
in the kidneys and produce kidney failure. The connection between rhabdomyolysis, myoglobinuria, and acute
kidney failure is complex and is still not completely understood, but is thought to be due to kidney tubular
injury.37 While most cases of rhabdomyolysis result in myoglobinuria, only 5-7% of the cases of rhabdomyolysis
result in acute kidney failure.5, 52
In contrast, not all dark urine in athletes is due to rhabdomyolysis. Sometimes hematuria (intact red cells in the
urine) causes the dark color of urine. "Bloody urine" in marathon runners is common and is generally not due to
rhabdomyolysis but in stead from running on an empty bladder. 16
History
Perhaps the first recognition of rhabdomyolysis causing acute kidney failure was noted in London during World
War II bombings that left patients suffering from crush injuries to muscles. 28 These types of injuries are seen in
auto accidents and in “collision” sports such as football. In crush injuries, rhabdomyolysis is generally due to
direct muscle trauma and not overexertion. rhabdomyolysis from over exertional is a less recognized diagnosis.
Boot Camps and Rhabdomyolysis
Boot camps have a constant flow of new unconditioned trainees which is probably why rhabdomyolysis has
been documented in military boot camps as early as the 1960s. In 1959, six cases of myoglobinuria and muscle
pain were recorded in the U.S. Army hospital by recruits undergoing Army basic training in Fort Jackson, South
Carolina.59 In the late 1960s, eight young naval aviation officer candidates were referred to the Naval
Aerospace Medical Institute because of discolored urine and severe muscle pain. 54 Each of the candidates had
performed unaccustomed and strenuous exercise in the preceding 38 hours prior to the symptoms. All eight
recruits exhibited impaired muscle function and elevated blood levels of muscle enzymes (creatine kinase –
CK). Their return to normal function took several weeks.
2
After repeated days of high volume squat jumps, push-ups, pull-ups, or rope climbs, 40 Marine Corp recruits
were hospitalized in Beaufort, South Carolina.12 During the first two weeks of officer candidate training at Fort
Benning, Georgia, 33 (5.5%) of 586 recruits exhibited brown urine and other symptoms of rhabdomyolysis.19
Most candidates required two to three weeks for recovery of muscle function. However, eight recruits continued
to have decreased muscle function after six weeks, with one recruit not fully recovered after three months.
In each of these reports, strenuous, repetitive, callisthenic-type exercises (pushups, pull-ups, squats) performed
on the first few days of training produced rhabdomyolysis, but not kidney failure. A high volume of same
exercise, would classify even a familiar exercise as novel to conditioned as well as unconditioned individuals
Due to the specificity of exercise, it is unlikely that new recruits would be conditioned for such exercise levels.
There may well be a higher incidence of milder cases, but because of the boot camp setting, many of the cases
undoubtedly go unrecognized and are overlooked as simple muscle strain. 12
Rhabdomyolysis in Athletics and Exercise
Externally “motivated” exertion is no the only situation where this type of rhabdomyolysis occurs. Many case
reports document major rhabdomyolysis after novel overexertion, including body building 6, weight lifting 22, gym
workouts, 49 sit-ups 20, deep knee bends, 7 cycling against resistance, 52 riding a mechanical bull, 42 or walking
down into the Grand Canyon. 40 A brief sampling of the research reveals the following:
Researchers found that 25 of 44 runners who completed a 99 km road race demonstrated increases in blood
levels of myoglobin, CK, and other muscle enzymes, but detected myoglobin in the urine samples of only six
runners. None had acute kidney failure. In another study, 24 athletes who had competed in a triathlon showed
a dramatic rise in blood myoglobin levels and muscle pain, but none were hospitalized. 49
In the fall of 1997, three college wrestlers who were restricting their food and fluids intake (they may have been
taking ephedrine) and wearing plastic suits while exercising to exhaustion in hot rooms (in order to sweat
weight) died. Rhabdomyolysis was listed as the official cause of death in one. 44
Other researchers reported that three young men who had regularly engaged in sport activity (but not body
building exercises) prior to an exercise session complained of muscle pain and dark urine after participating in
the first session of a bodybuilding program. Still others noted a case of an individual who developed
rhabdomyolysis and heavy myoglobinuria after a vigorous squash session. He was treated with dialysis and did
not develop kidney failure.14
The incidence of rhabdomyolysis is higher in males, but this is probably behavioral, not biologic, because men
and women respond equally to high-force eccentric exercise. 45
3
Recreational setting
Other less organized settings can also produce problems. A vacationing 25-year old woman went on a fourhour walk down into the Grand Canyon in September 1987 and collapsed into unconsciousness. She was air
lifted to a local hospital with an 8000% increase in creatine kinase (muscle) enzyme levels in her blood. She
subsequently recovered, though dialysis was required for six weeks to compensate for kidney failure.
Even increases in non-competitive isolated exercise programs, particularly exercises of the abdominal wall such
as "abdominal crunches" and sit-ups can, induce rhabdomyolysis. For example a 29 year old man who had
started performing 30 to 40 sit ups a day for five days showed abnormal blood creatine kinase (CK) levels after
a week of rest. 26
Jail Setting
An individual incarcerated at the Whatcom County Jail, complained of blood in his urine, headache, and nausea.
The Medical Staff gave him antibiotics and did a follow up the next day. The Inmate relayed he had done 300
squats with his mattress a day or two before receiving the antibiotics, and still complained of the same
symptoms. He was then sent to the ER for further tests, at which time he was admitted.
Due to the nature of his charge, we provided security for 4 days. He was diagnosed with Rhabdomyolysis, then
placed on kidney dialysis, at which time his hold was dropped. Because of patient confidentiality issues, we
were unable to find out how long he was on dialysis.
What goes wrong?
What exactly occurs during excessive exercise to cause muscle damage is not fully understood. Eccentric
accentuated type movements (any activity that has a high amount of bouncing such as rope-jumping, running,
box jumping push-ups, sit ups) seem to be a common class of movement that plays a part in this problem.
Rhabdomyolysis rarely if ever occurs from a single overload that would cause a muscle tear or rupture. In an
experiment to study eccentric exercise protocol, two sets of 25 maximal eccentric contractions of the biceps
were performed, separated by a 5-min rest period. This produced extreme swelling of the exercised arm lasting
several weeks, and greatly elevated blood creatine kinase levels. A 3% rate of prolonged losses in muscle
function lasting 43-47 days was observed.45 Anyone who has performed forced “negative” repetitions is familiar
4
with the severe muscle soreness that such exercise can produce. This soreness and damage is probably
related to the shock absorber role played by the Series Elastic Component (the connective tissue between the
cells) of the muscle. This intercellular connective tissue acts like a spring to absorb energy during the eccentric
(lengthening) phase of muscle activity. If overloaded, this tissue will fatigue and tear, opening the cell and
allowing muscle contents such as myoglobin to diffuse into the surrounding spaces and into the blood. It may
also be due to the inability of the muscle cell to keep up with the energy demand of the muscle’s metabolic
processes and the production of chemical free radicals. Alternatively the deciding factor for the origin of the
problem may vary depending on the factors contributing to the damage.
Contributing factors:
Several contributing factors play a role in rhabdomyolysis and it is known that some individuals are more
“genetically at risk” for damage to the muscles during intense exercise. Since genetic predispositions are not
readily observable to officers or trainers, the first obvious contributing factor is high volume or intense novel
exercise done in a very short period. A second factor is dehydration. Third are stimulants such as caffeine,
ephedrine, dipheniydramine, theophylline, cocaine, and methamphetamine. Fourth is high ambient
temperatures and hyperthermia (elevated body temperature). Fifth is - influenza like illnesses. Sixth may be the
intake of alcohol or certain prescription drugs. Dietary manipulation or nutritional supplements may play a role
as well.
Signs and Symptoms
While heavy exercise can cause delayed muscle soreness 24-48 hours after the exertion with decreased
function for a short period of time, this is not likely rhabdomyolysis. The signs and symptoms of rhabdomyolysis
include swelling in the affected muscles, muscle pain, persistent muscle weakness, and dark urine. These can
appear shortly after the damaging exercise and can persist for weeks. If the exertion occurred in hot humid
weather with limited fluids or any of the other factors listed above drink plenty of fluids and see a doctor.
Hyperthermia and Rhabdomyolysis
Many researchers have implicated hyperthermia or increased body temperature, as a contributing factor to
rhabdomyolysis. Hyperthermia may be from exercise, the environment, drugs, or a combination of all three.
Clinical reports and animal studies indicate that hyperthermia is a major effect of psychostimulant drugs that can
5
occur independently of seizures or increased muscle activity. Although hyperthermia is not a requirement for
muscle damage, the association between heat stroke, rhabdomyolysis, and acute kidney failure is very strong.
In 1967 kidney failure was documented in army recruits from 1958-1965 who had participated in their first
sessions of basic training.
61
During that period, 2 of 10 recruits who had kidney failure died. The autopsy of
one recruit discovered extensive death of the pectoralis muscles (from push ups). While a surgical
decompression of the shin muscle (tibialis anterior) was required on the other individual; it too, revealed
extensive muscle death from excessive marching. All 10 recruits had experienced heat stroke or heat stress,
and their state of hydration was compromised.
Significant correlations were also noted by researchers between blood levels of myoglobin and post-exercise
body temperatures in 24 athletes completing a triathlon. 57 This is important as it underscores that even
conditioned individuals are susceptible to over-exertional injury given the right conditions.
The deceased Massachusetts police cadet mentioned above, exercised at temperatures ranging from 80-83° F.
Although this is generally not high enough to cause heat stroke, it is high enough to result in significant body
water loss through sweating. The cadet's rectal temperature upon hospital admission was 105° F and he
displayed classical signs of heat stroke. 23
The effects of rhabdomyolysis on the kidney appear more pronounced when one is dehydrated. Animal studies
have shown that myoglobin in the blood does not cause kidney failure as long as urine flow is sufficient.
28
The
presence of heat stress is a common factor in cases of acute kidney failure which appears to be more likely
when dehydration is present. 37
As noted above, dehydration and heat stress are not absolute prerequisites for exercise induced kidney failure.
Seven healthy, active individuals developed kidney failure requiring dialysis after performing cross-country runs
ranging from 10-15 km (6 individuals) or after a three-day march of 90 km (1 individual). 60 No evidence of heat
stress or dehydration was found in any of these participants. Indications of rhabdomyolysis, including
myoglobinuria (all 7), low blood levels of calcium (in 3), and high blood levels of potassium (in 4), were present
at the time of care.
Infections, Drugs and Diet
High temperatures and lack of water contribute to the problem of rhabdomyolysis and kidney damage, diet and
health and drugs both prescription and illicit can also play a role. Additionally both viral and bacterial infections
have been associated with exertional rhabdomyolysis in athletes.
27, 36
In the academy setting or in courses that last for a week or more the instructor has a better chance to identify
health and performance that is not at an individual’s baseline level. Consequently, if the instructor notes signs
of illness or the individual reports fever and muscle aches; the best advice is to not participate, work-out or try to
“sweat it out”.
6
Performance based dietary manipulation is unlikely to occur in either an academy setting or with your in-service
students. However certain individuals looking to reduce their body fat may be on a low carbohydrate diet. This
type of diet can be similar in its effect to the “depletion phase” of the performance based carbo-loading practice.
In spite of the fact that carbohydrate loading has been performed by numerous athletes with no negative effects,
diet manipulation of this type has been associated with exertional rhabdomyolysis. A 34-year old avid runner
exercised and performed the typical carbohydrate depletion/loading regimen a few days before a 10-kilometer
race. He then completed the race in ambient temperatures of 87° and collapsed. Within 30 minutes he was
admitted to a hospital where he died shortly after from rhabdomyolysis and heat stroke.
29
Other examples of
well-trained runners who performed the carbohydrate loading and reported brown urine after running or required
treatment for kidney failure can also be found in the literature.
4
Other dietary manipulations have been suspected to contribute to rhabdomyolysis. Chromium picolinate, a
nutritional supplement, was suspected to be the cause of rhabdomyolysis in a 24-year-old body builder who
developed the syndrome after ingesting 1200 micrograms of chromium picolinate (6-24 times the daily
recommended allowance) over 48 hours.
consumption of quail!
25
Another reported and rather strange dietary factor is the over
(Rhabdomyolysis after the consumption of quail is well-known in the Mediterranean
region; it occurs as the result of intoxication by hemlock herbs that the quails consume.)
While not typically thought of as a dietary manipulation, alcohol can be a leading cause of rhabdomyolysis in
populations prone to over indulgence.
61
A 25-year-old male checked into a hospital with low urine flow and
bilateral leg pain two days after an alcoholic binge. He subsequently developed rhabdomyolysis causing acute
kidney failure, with compartment syndrome of both lower legs (swollen muscles). Urgent dialysis and surgical
decompression (fasciotomy) for his legs were required within six hours of his admission. He remained on
dialysis for three weeks and only after four months was he able to bear weight on both legs
56.
In addition to alcohol, prescriptive drugs and over the counter drugs have been noted as contributing to muscle
damage. Exertional rhabdomyolysis can also occur from use of cholesterol-lowering drugs. In one study of
about 40 patients on lovastatin or fluvastatin, four men developed dramatic increases in creatine kinase after
exercise and one had severe myalgia
58.
These "statin" drugs may be only in limited use with your in-service
training population, but you should remain alert to the possibility of rhabdomyolysis in older trainees who are
sore, stiff, and tired beyond what might be expected for the level of exertion reached in class.
A case of rhabdomyolysis with attendant severe acute kidney failure in a 59-year-old male patient (paranoia
schizophrenia) being treated with haloperidol-decanoate, was noted when was hospitalized after weekly
catatonic episodes. On examination he had the typical signs of rhabdomyolysis with swelling to the lower limbs.
Laboratory findings confirmed rhabdomyolysis and severe kidney failure. This is often referred to as neuroleptic
malignant syndrome and can be the cause of sudden death when officers arrest and restrain “mental”
patients.32,33 This helps illustrate the need for information gathering both prior to and at the scene of such a call.
7
Psychostimulant drugs can contribute to rhabdomyolysis.
Anecdotal evidence implicates cocaine, amphetamine (and their derivatives), and perhaps caffeine and ephedra
related products.
9
Dr. Charles Wetli has examined the connection between rhabdomyolysis and the causes of
cocaine excited delirium deaths. He and his colleagues in 1997 described deaths that occurred between 1979
and 1990 from cocaine-induced excited delirium in Dade County, Florida.46 Then again in 1999, Wetli et.al.
compared data from 150 reported cases of cocaine-associated rhabdomyolysis with data from an autopsy
registry for victims of fatal excited delirium (N=58) and victims of fatal acute cocaine toxicity (N=125). He
concluded that cocaine-associated rhabdomyolysis and fatal excited delirium are different stages of the same
syndrome. Their findings were consistent with the theory that chronic cocaine use disrupts specific neural
functions which when coupled with recent cocaine use, may precipitate agitation, delirium, hyperthermia,
rhabdomyolysis, and sudden death. 47
In part 2 we will look at the way overexertion and rhabdomyolysis may play a role in sudden in-custody deaths
as well as recommendations to minimize the risks of this oddity of too much exercise.
______________________________________________________________________________________
in partr one we defined exertional rhabdomyolysis as damage to the muscle cells that is characterized by a
group of conditions including muscle pain, tenderness, weakness, swelling, increased levels of muscle
components in the blood and urine after strenuous, overexertion or exercise.
We also discussed the
contributing factors. In part two we will continue with how rhabdomyolysis and over exertion may be associated
with in-custody deaths and ways to minimize the risk of overexertion.
In custody deaths, over-exertion and electrolyte imbalance.
By this point it is obvious that over exertion plays a role in the muscle damage. A fallout of this damage can be
blood electrolyte imbalance. Now we’re not talking an overdose of Gatorade here, but severe elevation of
potassium in the blood, known as hyperkalemia. Potassium is released into the circulation from damaged
muscle cells.
24
Hyperkalemia can also result from kidney failure, when the kidneys are unable to excrete
potassium in sufficient quantity.
35, 37
Hyperkalemia is a common electrolyte abnormality found in about 50% of
patients suffering from exertional rhabdomyolysis.
24
Excessive levels of potassium in the blood are potentially
lethal because they can lead to deadly arrhythmias and cardiac arrest as well as skeletal muscle weakness.
35
Calcium leaving the blood and depositing in the injured muscle (hypocalcaemia) worsens the hyperkalemia
toxicity. Again a preventative measure is to drink plenty of water during heavy exertion and stay away from the
caffeine.
It is interesting to note the connection between high levels of stimulants and the potential for rhabdomyolysis,
kidney damage and in-custody deaths and the capture of wild animals. Years ago when talking with current
board member and Florida game agent Kat Kelley she noted that the issues of in-custody deaths had striking
similarities to deaths associated with the capture of wild animals.
8
On a typical night of work, police will
commonly respond to a call of a suspicious or “crazy” person. Upon making contact the suspect appears overstimulated (via drugs or mania), sweating (dehydrated) and highly resistant. Only occasionally does the wild
violator who fights with police end up dying in-custody. These fights are notoriously protracted and require
multiple officers to effect the arrest. The violator appears to be impervious to pain and resists without regard for
their own well-being and because the violator commonly continues to fight against the handcuffs, officers often
liken these arrests to fighting a wild animal.
This scenario is extremely similar to what's called “capture
myopathy” or the “capture death syndrome” where one sees a very protracted chase, which precedes capture of
the animal. The animal then continues to struggle and fight during the capture (restraint) portion and ultimately
suffers severe muscle damage and death. Using this “chase, fight and cage” method of animal capture many
animals died immediately or within a week of capture. The introduction of tranquilizers to reduce the over
exertion greatly increased the animals’ survival rates. (see Spraker)
This, I believe has direct implications to the arrest of wildly resistant violators. No, I am not suggesting that
officers be issued tranquilizer guns, but that once it is clear that the irrational violator is in the “wild animal mode”
the officer should employ tactics that will end the fight immediately. Examples of such safe and effective
procedures to eliminate the over exertion, are the use of the TASER and the LVNR.
Susceptible Individuals
But why, you ask, are some individuals more susceptible to rhabdomyolysis than others? Certainly there are
some rare individuals with a hereditary muscle enzyme defect or metabolic disorders that can cause mild
ongoing or exertional rhabdomyolysis.
Under normal exercise stress their condition would probably go
unnoticed, but in a competitive event (manic or drug induced as well) the fervor to win or the disgrace of quitting
may provide the motivation to allow these individuals to drive themselves beyond pain tolerance and to a level
that causes muscle damage.
1,15,29,39,58
Some individuals may be more susceptible to heat stress. Individuals
who have suffered prior heat stress may have a persistent, hidden metabolic disorder that predisposed them to
heat stress and rhabdomyolysis such as malignant hyperthermia.
34
Heat stress susceptibility is certainly
influenced by the individual’s state of hydration as well as by the state of acclimatization. Lastly, the physical
condition of an individual when performing strenuous unaccustomed exercise may be a factor in determining
susceptibility to rhabdomyolysis.
At a glance, the statistics on exertional rhabdomyolysis appear startling, but fortunately there are relatively few
severe documented cases. However when they do occur, these cases are splashed across the headlines in the
press, (as in the case of in-custody deaths) the result can be devastating to the families and the agency
involved. Obviously when possible the “ounce of prevention” applied in such a case is worth not just a pound of
cure, but perhaps millions of dollars as well.
9
Prevention and Recognition
By looking at these examples is easy to see the common errors that occur both from a procedure standpoint
and from a training and education aspect. Once this peculiar malady is understood steps can be taken to
recognize (train those in the physical training arena to know the signs) situations that may cause
rhabdomyolysis and how the afflicted individual may appear. Prevention measures may differ depending upon
the actual situation or setting. The arrest situation will differ from training in the academy, in-service or highly
specialized settings.
In a sentence, the problem can probably be avoided by common sense behavior such as a gradual increase in
exercise intensity, plenty of water before, during, and after exercise, and avoiding exercise in extremely hot
humid environments or with a fever. (Remember too much of anything can kill you, even water, don’t drink
gallons of water or you may end up dead as has happened in a number of marathons). Unfortunately as they
say “common sense is not so common” especially in the world of exercise. Merely having exercised or being fit
does not mean one really knows anything about the safe and sound principles of exercise training (recall the
Marine DI above). It is important to complete some form of a Certified Fitness Coordinator course or utilize
someone who has such credentials when designing physical training programs.
A second approach to academy and specialized training courses is to have scientifically valid physical entrance
requirements or standards. To be sure, many courses have some type of physical fitness entrance standards,
but they may not be truly valid or representative of the exact demands. It is absolutely clear that general
physical fitness may not be protective with regard to highly specific and intense physical exercise. The actual
training demands must be analyzed by a qualified exercise training specialist with a subsequent test designed to
represent the specific repetitive movements of the training.
What exactly qualifies as a scientifically valid and legally defensible standard is best dealt with in a separate and
more extensive article. Suffice to say just because you think it makes sense or you asked a few “experts” their
advice, you have not made the standard a valid standard, especially in the eyes of the law.
Academy training
If there are no valid entrance physical requirements, then it is recommended that within the academy setting,
exercise programs should begin with mild intensity exercise and should gradually build up to the needed level.
The reason for this recommendation is to prevent undue muscle soreness on subsequent days. As mentioned
above, researchers agree most cases of heat stress, rhabdomyolysis, and acute kidney failure occurred during
the first days of training, when excessive repetitive exercises (e.g., push-ups, squat jumps) have been used.
Even a fit jogger or swimmer won't necessarily tolerate dozens of pull-ups, 100 squat jumps or 300 push-ups
because fitness is very specific to the imposed demands. Many police training facilities are now aware of this
potential hazard, and the use of these forms of exercise as punishment, has been wisely eliminated.
10
Remember, for those individuals predisposed to severe exertional rhabdomyolysis, starting up gradually could
save their lives.
In-service training and valid entrance requirements
For mandatory in-service training other factors need to be considered before performing strenuous exercise,
especially in a warm/hot environment.
Diet, fluid intake, the degree of acclimatization, prescription drugs,
(diuretics lower blood levels of potassium and promote dehydration) and the level of conditioning of your
“students” should be assessed before training starts. Warm ups should be just that - warm ups - not a work-out
in itself. Through proper instructional techniques there are many ways to make physical tactics training more
“energy efficient” or easier to tolerate by the less conditioned participants. Again adequate fluid should be
available and encouraged before and during exercise.
SWAT and other specialized Training and valid entrance requirements.
As the world of police services evolves, the variety of specialized teams and the associated training have grown
dramatically (see past issues of the LET). Much of this training is logically similar to intense military training.
Unfortunately the training and required physical condition may be vastly different from that which is possessed
by the participants in the new training. Novel equipment and training demands can cause some individuals who
have never had any prior related symptoms (maybe even those who completed a marathon or performed other
strenuous activities) to collapse, needing hospitalization. While disturbing and sometimes tragic, these cases
are rare. The key again is to assess the skill and the training methodology. There are many unrelated and
strenuous training activities that occur at all levels of training that may needlessly contribute to injuries. Always
ask, “is this activity truly related to the skill that is being trained?”
Once the training regimen is properly
identified then appropriate entrance requirements can be developed.
In-custody deaths, end the fight as soon as possible - LVNR could be a life saving tool.
Given the above information on exertional rhabdomyolysis and its resultant problems that may cause sudden or
delayed death in both humans and animals, one can begin to form a clearer picture of the misunderstandings
surrounding the cause of in-custody deaths, most notably, positional asphyxia. Dr. Ted Chan (who will be
presenting at the Ontario conference in 2003) and others have used good science to dispel the
misunderstandings in this area. The scientific and anecdotal evidence in regard to exertional rhabdomyolysis
provides a better theoretical model for sudden in-custody deaths.
Because the responding officer cannot be expected to know the violator’s genetic susceptibility to exertional
stress, the level of conditioning, state of hydration, amount and type of drugs in the blood or their mind-set, he or
she must respond only to those observable and actions that require law enforcement intervention. As noted
11
earlier, one of the common denominators that may result in the deadly cascade of events that lead to injury or
death is overexertion. Therefore it stands to reason that the best response to a violent resistor is to end the
“over exertion” as fast as possible.
The safest and surest way to reduce the length and level of severe
resistance is through the use of a Taser or a safe neck restraint such as the LVNR. Anecdotal evidence shows
that nearly 75% of “rational” resistors cease their resistance prior to being rendered unconscious with the LVNR.
For those who are willing to fight through pain and resist with wild abandon the LVNR is an incapacitation
technique causing immediate cessation of violent resistance, thus eliminating the additional exertional stress of
an arrest by using “brute force”.
Officers must always be cognizant of the rare situation that may lead to an in-custody death. Signs that may
signal a potential “problem person” are 1) long protracted physical confrontation, usually 3 minutes or longer; 2)
The person is known to have mental problems; 3) There are drugs involved, especially stimulants; 4) The
environment is hot or the violator exhibits signs of heat stress; 5)The violator is obese.
None of these signs either together or individually are a sure indication of a problem. However, the more of
these signs that are present, the more suspicious and concerned the officer should be about exertional stress.
Ultimately it is up to the officer to decide the need for force and apprehension at the time of the contact.
Providing the officer with the proper training and the tools can make “calming the savage beast” safer for
citizens and officers alike.
Summary and recommendations
Strenuous unaccustomed exercise can cause muscle fiber damage and degradation. This condition is called
exertional rhabdomyolysis and is manifested by a muscle weakness, swelling, and pain; “iced-tea-pee”; and
increased levels of muscle proteins and other cellular contents in the blood. Drugs, diet manipulation, and
genetic defects aside, performance of unfamiliar, excessive, repetitive exercises such as push-ups and squatjumps is typically the main causative agent. Rhabdomyolysis can also occur after voluntary, strenuous activities
such as marathon running, hiking, or performance of excessive strenuous exercise during the first days of a new
training program. Mild cases of rhabdomyolysis do not require hospitalization, and victims recover within one
week. However, in certain individuals, the combination of heat stress (hyperthermia) and rhabdomyolysis can
produce acute kidney failure, which, in rare instances, can result in death. Alarmingly, those few individuals who
have developed severe rhabdomyolysis commonly have never shown any prior symptoms. When a trainee
collapses from overexertion and/or heat stroke, the proverbial "pound of cure," i.e., prompt treatment, is
imperative. Most individuals who receive immediate medical attention survive. However, their recovery may be
very slow. In the case of the woman who had hiked down the Grand Canyon, hospitalization was necessary for
seven weeks. In the case of one of the military trainees in Officers Candidate School, hospitalization was
required for three months, and muscle weakness was still apparent five months after the episode of exertional
rhabdomyolysis. So what to do? Listed below are some simple recommendations.
12
1.
Limit participation in repetitive exercise during the first few days of a new training regimen – do much
less than you think you can do. Limit participation in a strenuous recreational activity unless you are
well-conditioned for that specific activity.
2.
Drink plenty of fluids even if ambient temperatures are only warm. Never try a new diet manipulation
prior to a competitive strenuous exercise without first having done so with a lower intensity exercise.
Never use diuretics prior to strenuous exercise. Never exercise if you are feeling ill or have a fever.
3.
If you feel dizzy or disoriented during exercise, especially if ambient temperatures are warm and
sweating is profuse, immediately stop and rest.
Any participant who collapses during strenuous
exercise must receive prompt medical attention.
4.
If you experience dark urine on the day or two after performance of a strenuous, novel exercise, consult
your physician immediately. Although dark urine could indicate the presence of myoglobin in the urine,
it could also indicate no more than a benign, self-limiting condition experienced by some endurance
athletes. Laboratory analyses of blood and urine samples are necessary to determine whether the
condition is potentially serious or harmless.
5.
End violent resistive confrontations as soon as possible with techniques designed to immediately
conclude the situation with minimal exertion allowed by the violator.
About the author: Bob Bragg has been the Supervisor of Fitness Force and Training for the Washington State
Criminal Justice Training Commission for the past 20 years and trained thousands of Law Enforcement and
Corrections Officers and hundreds of instructors in the areas of use of force. Bob holds a MS in the area of
exercise physiology and sports medicine. Bob welcomes your comments and can be contacted at
rbragg@cjtc.state.wa.us.
13
Self test
1.
Exertional rhabdomyolysis is the degeneration of skeletal muscle caused by excessive unaccustomed
exercise. The visible symptoms of rhabdomyolysis include what four things? Muscle pain, weakness,
and swelling; dark colored urine. Increased levels of muscle enzymes and other constituents in the
blood can only be determined by blood testing.
2.
Myoglobinuria occurs when one drinks:
Coke during strenuous exercise.
iced tea during strenuous exercise.
too little water during strenuous exercise.
3.
Which of the following are contributing factors to exertional rhabdomyolysis
alcohol ingestion
dehydration
poor acclimatization to hot weather
viral influenza
4.
The danger of myoglobin in the blood is that it can
Collect in the kidneys and cause kidney failure.
Collect around the heart valves and produce heart failure.
Constrict the capillaries in the brain and cause a stroke.
All of the above when water intake is restricted.
5.
According to Wetli, et. al. exertional rhabdomyolysis, acute exhaustive mania, and cocaine psychosis
are different stages of the same malady. T or F.
6.
Certain individuals may be predisposed to rhabdomyolysis, possibly due to a hidden genetic disorder.
T or F
7.
Exertional rhabdomyolysis has resulted in the death of some young, apparently healthy individuals.
T or F.
8.
Insufficient acclimatization, inadequate diet, and lack of specific physical conditioning may also
contribute to this condition and therefore overall fitness will be good aerobic fitness level will prevent
exertional rhabdomyolysis. T or F.
14
9.
Severe incidents of rhabdomyolysis tend to occur at the initiation of a training program when exercise is
excessive and accompanied by heat stress and dehydration. T or F.
10.
Animal capture syndrome is a similar disorder to exertional rhabdomyolysis seen in wild animals.
T or F.
11.
The LVNR has been recommended as a simple and safe method to quickly end violent resistance,
minimize violator exercise, and reduce exertional rhabdomyolysis and resultant sudden death. T or F.
pull quotes
Excessive levels of potassium in the blood are potentially lethal because they can lead to
deadly arrhythmias and cardiac arrest
An approach to academy and specialized training courses is to have scientifically valid
physical entrance requirements or standards
15
Partial List of References
1. Argov, Z. and Mastaglia, F.L. (1994) Drug-induced neuromuscular disorders in man. In: Walton, J.,
Karpati, G., and Hilton-Jones, D. (Eds) Disorders of Voluntary Muscle (6th ed). New York: Churchill
Livingstone, 989-1029.
2. Argov Z DiMauro S Recurrent exertional myalgia and myoglobinuria due to carnitine palmityltransferase
deficiency Israel Journal of Medical Sciences 1983; 19 552- 54.
3. Baggaley, P.A., (1997) Rhabdomyolysis webpage.
4. Bank, W.J. (1977) Myoglobinuria in marathon runners: possible relationship to carbohydrate and lipid
metabolism. Ann. NY Acad. Sci., 301:942-948.
5. Bartlett, J.C. (1985) Rhabdomyolysis of the upper extremities associated with weight lifting: report of a
case. J. Am Osteopath. Assoc., 85:646-648.
6. Bolgiano EB Acute rhabdomyolysis due to body building exercise Journal of Sports Medicine and
Physical Fitness 1994; 34: 76- 8.
7. Bolyard E et al., Challenge, 110 deep knee bends; reward, rhabdomyolysis New England Journal of
Medicine 1994; 330: 1620- 1.
8. Brown, J., Mitchell, S. (1992) A complicated case of exertional heat stroke in a military setting with
persistent elevation of creatine phosphokinase. Mil. Med., 157:101-103.
9. Callaway CW, Clark RF. Hyperthermia in psychostimulant overdose. Ann Emerg Med 1994
Jul;24(1):68-76
10. Clarkson, P.M. (Jan., 1990) Too much too soon: The aftermath of overexertion. Sports Sci. Exchange, 2
(21).
11. Cowart, V.S. (1990) Some unusual hurdles en route to fitness. JAMA, 264: 1798-1801.
12. Demos, M.A., Gitin, E.L. (1974) Acute exertional rhabdomyolysis. Arch. Internal Med., 133:233-239.
13. Demos, M.A., Gitin, E.L., Kagen, L.J. (1974) Exercise myoglobinemia and acute exertional
rhabdomyolysis. Arch. Internal Med., 134:669-673.
14. Doriguzzi, C., Palmucci, L., Mongini, T., Arnaudo, E., Bet, L., Bresolin, N. (1988) Body building and
myoglobinuria: Report of three cases. Br. Med. J., 296:826-827.
15. Doriguzzi C et al., Exercise intolerance and recurrent myoglobinuria as the only expression of Xp21
Becker type muscular dystrophy Journal of Neurology 1993; 240: 269- 71.
16. Eichner, ER Exertional Hyponatremia, Sports Med Dig. May 2002 Vol 24, #5
17. Eichner, ER Rhabdo Redux: Further Vagaries of Exertional Rhabdomyolysis, Sports Med Dig. May
2003 Vol 25,#5
18. Fred, H.L., Natelson, E.A. (1977) Grossly bloody urine of runners. Southern Med. J., 70:1394-1396.
19. Gitin L Demos MA Acute exertional rhabdomyolysis: A syndrome of increasing importance to the military
physician Military Medicine 1974; 139: 33- 6.
20. Goodman A et al., Exertional rhabdomyolysis and acute renal impairment-New York City and
Massachusetts, 1988 Morbidity and Mortality Weekly Report 1990; 39: 751- 6.
21. Goubier, J-N, Silbermann, 0 Hoffman, Oberlin, C (2002) Exertion induced rhabdomyolysis of the long
head of the triceps. BRITISH JOURNAL OF SPORTS MEDICINE, April 2002. Vol 36. No 2. P 150-151
22. Greenberg, J., Arneson, L. (1967) Exertional rhabdomyolysis with myoglobinuria in a large group of
military trainees. Neurology, 17:216-222.
23. Gronert, G.A. (1986) Malignant Hyperthermia. In: Engel, A.G, and Banker, B.Q. (Eds) Myology, Vol 2.
New York: McGraw-Hill, 1763-1784.
24. Guzé, B.H. and Baxter, L.R. (1985) Neuroleptic Malignant Syndrome. NEJM 313(3): 163-166.
25. Haas DC Bohnker BK "Abdominal crunch"-induced rhabdomyolysis presenting as right upper quadrant
pain Military Medicine 1999; 164: 160- 1.
26. Hamilton, R.W., Hopkins, M.B., Shihabi, Z.K. (1989) Myoglobinuria, hemoglobinuria, and acute renal
failure. Clin. Chem., 35:1713-1720.
27. Hamer R When exercise goes awry: Exertional rhabdomyolysis Southern Medical Journal 1997; 90:
549- 51.
28. Hassanein, T., Perper, J.A., Tepperman, L., Starzl, T.E., Van Thiel, D.H. (1991) Liver failure occurring
as a component of exertional heatstroke. Gastronenterology, 100:1442-1447.
29. Honda, N., Kurokawa, K. (1983) Acute renal failure and rhabdomyolysis. Kidney Internat., 23:888-898.
30. Kakulas, B.A. and Mastaglia, F.L. (1992) Drug-induced, toxic and nutritional myopathies. In: Mastaglia,
F.L. and Walton, J. (Eds) Skeletal Muscle Pathology (2nd ed). New York : Churchill Livingstone, 511540.
16
31. Kao PF; Tzen KY; Chen JY; Lin KJ; Tsai MF; Yen TC: Rectus abdominis rhabdomyolysis after sit-ups:
unexpected detection by bone scan, Br J Sports Med 1998 Sep;32(3):253-4
32. Keverline JP Recurrent rhabdomyolysis associated with influenza-like illness in a weight-lifter Journal of
Sports Medicine and Physical Fitness 1998; 38: 177- 9.
33. Knochel, J.P. (1982) Rhabdomyolysis and myoglobinuria. Ann. Rev. of Med., 33:435-443.
34. Knochel, J.P. (1990) Catastrophic medical events with exhaustive exercise: "White collar
rhabdomyolysis." Kidney Internat. 38:709-719.
35. Knochel, J.P. (1992) Hypophosphataemia and rhabdomyolysis. JAMA 92: 455-457.
36. Knochel, J.P. (1993) Mechanisms of rhabdomyolysis. Current Opinion in Rheumatology 5: 725-731.
37. Laposata, E.A., Hale, P., Jr., and Poklis, A.,"Evaluation of Sudden Death in Psychiatric Patients with
Special Reference to Phenothiazine Therapy: Forensic Pathology," Jour Forensic Sciences, JFSCA,
Vol. 33, No. 2, March 1988, pp. 432-440.
38. Lazzarin M; Benati F; Cesario V: Rhabdomyolysis and acute renal failure caused by haloperidoldecanoate (neuroleptic malignant syndrome): Recenti Prog Med 1996 Sep;87(9):422-4
39. Legros P., Jehenson, P., Gascard, J.P., Kozak-Reiss, G. (1992) Long-term relationship between acute
rhabdomyolysis and abnormal high energy phosphate metabolism potentiated by ischemic exercise.
Med. Sci. Sports Exerc., 24:298-302.
40. Marieb, E.N. (1992) Human Anatomy and Physiology, 2nd. Ed. Benjamin/Cummings Pub. Co., Inc.:
Redwood City, CA, pp. 628 & 912.
41. Marinella MA, Exertional rhabdomyolysis after recent coxsackie B virus infection Southern Medical
Journal 1998; 91: 1057- 9.
42. Milne C.J. (1988) Rhabdomyolysis, myoglobinuria and exercise. Sports Med., 6:93-106.
43. Nagashima, T., Tanabe, H., Nagashima, K. (1987) Myoglobin immunohistochemical studies on
rhabdomyolysis with acute renal failure. Acta. Histochem. Cytochem., 20:489-493.
44. Noakes, T.D. (1987) Effect of exercise on serum enzyme activities in humans. Sports Med., 4:245-267.
45. Pattison, M.E., Logan, J.L., Lee, S.M., Ogden, D.A. (1988) Exertional heat stroke and acute renal failure
in a young woman. Am. J. Kidney Dis., 11:184-187.
46. Penn, A.S. (1986) Myoglobinuria. In: Engel, A.G, and Banker, B.Q. (Eds) Myology, Vol 2. New York :
McGraw-Hill, 1785-1805.
47. Poels, P.J.E and Gabreëls, F.J.M. (1993) Rhabdomyolysis: a review of the literature. Clin Neurol &
Neurosurg 95: 175-192.
48. Powers RD et al., Urban-cowboy rhabdomyolysis New England Journal of Medicine 1981; 304: 427.
49. Remick D et al., Hyperthermia and dehydration-related deaths associated with intentional rapid weight
loss in three collegiate wrestlers-North Carolina, Wisconsin, and Michigan, November-December 1997
Morbidity and Mortality Weekly Report 1998; 47: 105- 8.
50. Rinard J et al., Response of male and females to high-force eccentric exercise Journal of Sports
Sciences 2000; 18: 229- 36.
51. Ruttenber AJ, Lawler-Heavner J, Yin M, Wetli CV, Hearn WL, Mash DC. Fatal excited delirium following
cocaine use: epidemiologic findings provide new evidence for mechanisms of cocaine toxicity. J
Forensic Sci 1997 Jan;42(1):25-31.
52. Ruttenber AJ; McAnally HB; Wetli CV, Cocaine-associated rhabdomyolysis and excited delirium:
different stages of the same syndrome. Am J Forensic Med Pathol 1999 Jun; 20 (2):120-7
53. Saad, E.B. (1997) Rhabdomyolysis and Myoglobinuria. (internet reference :
http://www.medstudents.com.br/terin/terin3.htm)
54. Sayers SP et al., Adverse events associated with eccentric exercise protocols: Six case studies
Medicine and Science in Sports and Exercise 1999; 31: 1697- 1702.
55. Schiff, H.B., MacSearraigh, E.T.M., Kallmeyer, J.C. (1978) Myoglobinuria, rhabdomyolysis, and
marathon running. Q.J. Med., New Series XLVII, No. 188:463-472.
56. Schimpf M et al., Exercise-induced rhabdomyolysis in a woman Clinical Journal of Sport Medicine 1999;
9: 233- 5.
57. Schulze, V.E. (1982) Rhabdomyolysis as a cause of acute renal failure. Postgrad. Med., 72: 145-157.
58. Sharma N et al., Exercise-induced rhabdomyolysis: Even the fit may suffer International Journal of
Clinical Practice 1999; 53: 476- 7.
59. Siegel, A.J., Hennekens, C.H., Solomon, H.S., Van Boeckel, B. (1979) Exercise-related hematuria:
Findings in a group of marathon runners. JAMA, 241:391-392.
60. Smith, R.F. (1968) Exertional rhabdomyolysis in Naval Officer Candidates. Arch. Internal Med., 121:313
-319.
17
61. Sofat N, Bell S, Turner J, Warrens AN A case of acute renal failure and compartment syndrome after an
alcoholic binge: J Accid Emerg Med 1999 Jul;16(4):296-8
62. Spraker, Terry R College of Veterinary Medicine Colorado State University. - An overview of the
pathophysiology of capture myopathy in wild animals and related conditions that occur at the time of
capture of wild animals. From Capture of North American Big Game
63. Thompson PD et al., Increases in creatine kinase after exercise in patients treated with HMG Co-A
reductase inhibitors Journal of the American Medical Association 1990; 264: 2992.
64. Thomas, B.D., Motley, C.P. (1984) Myoglobinemia and endurance exercise: A study of twenty-five
participants in a triathlon competition. Am. J. Sports Med., 12:113-119.
65. Treem WR Persistent elevation of transaminases as the presenting finding in an adolescent with an
unsuspected muscle glycogenosis Clinical Pediatrics 1987; 26: 605- 7.
66. Turell, D.J. (1961 ) Primary myoglobinuria and exercise-induced secondary myoglobinuria: A report of 7
cases seen at an army basic training center. Southern Med. J., 54:442-448.
67. Uberoi, H.S., Dugal, J.S., Kasthuri, A.S., Kolhe, V.S., Kumar, A.K., Cruz, S.A. (1991) Acute renal failure
in severe exertional rhabdomyolysis. J. Assoc. Physicians India, 39:677-679.
68. Vertel, R.M., Knochel, J.P. (1967) Acute renal failure due to heat injury. An analysis of ten cases
associated with a high incidence of myoglobinuria. Am. J. Med., 43:435-451.
69. Zajaczkowski, T., Potjan, G., Wojewski-Zajaczkowski, E., Straube, W. (1991) Rhabdomyolysis and
myoglobinuria associated with violent exercise and alcohol abuse: report of two cases. Internat. Urol.
Nephro. (Hungary), 23:517-525.
70. 3. Zager, R.A. (1996) Rhabdomyolysis and myohemoglobinuric acute renal failure. Kidney International
49 : 314-326.
Additional References
18