3 Keys to Preventing Rhabdomyolysis

(Originally published on Stack.com)

On March 10, the Associated Press reported that William Lowe, a former University of Iowa football player, filed a lawsuit against the university accusing the coaching staff of negligence. According to the AP report, Lowe alleges he was the victim of injuries sustained from a high-intensity off-season workout supervised by Hawkeye coaches and trainers on Jan. 20, 2011.

Lowe was one of 13 Iowa football players hospitalized and diagnosed with external rhabdomyolysis, a severe condition of the liver due to the release of muscle fiber contents into the bloodstream. Rhabdomyolysis has an assortment of causes, from car accidents to severe hydration. It can also be caused by extreme amounts of exercise, like an Ironman triathlon. Warning signs are extreme muscle soreness and dark-colored urine, caused by a substance known as myoglobinuria.

The reported culprit in the Hawkeyes football story was a Squat workout that lasted nearly 20 minutes: 100 Back Squats with a load equaling 50% of a one-rep max. In the lawsuit, Lowe is pursuing monetary damages for physical and mental anguish, contending that, “the injuries and damages [he] sustained . . . arose from the same general types of danger that [he] should have avoided through safe and proper athletic training and supervision.”

When the original story broke in 2011, rhabdomyolysis became the subject of much reporting and analysis in the mainstream sports media. As Iowa head football coach Kirk Ferentz acknowledged in a 2013 interview, the Squat workout had been performed several times in previous years with no adverse consequences, and it was only in the aftermath of the 2011 incident that they heard of the disorder.

“That whole incident is unfortunate in a lot of regards,” Ferentz said. “If you look back, no one really knew what rhabdo was at that point.”

“It can kill you.”

Indeed, college football is not what has been most frequently associated with rhabdomyolysis in the media. That dubious honor most certainly goes to the popular strength and conditioning program known as CrossFit. One of the first articles in the national press that identified rhabdomyolysis as a potential hazard of CrossFit appeared in The New York Times in 2005. In that article, CrossFit founder Greg Glassman spoke about the dangers of rhabdo. “It can kill you,” he said. “I’ve always been completely honest about that.”

In a more recent story, “CrossFit’s Dirty Little Secret,” Eric Robertson, an assistant professor of physical therapy, rekindled the controversy—in light of CrossFit’s spectacular growth over the last 5 years—trying to make the case that a future epidemic of CrossFit-created rhabdo cases will be the downfall of the program. He wrote, “My prediction: in a few years, the peer-reviewed scientific literature will be ripe with articles about CrossFit and rhabdomyolysis. Health providers will be there to scoop up the pieces, but who is there to protect those people unknowingly at risk?”

Robertson’s assertion prompted a fact-check by Mitra Hooshmand, Ph.D., a neuroscientist who publishes the blog, ScientiFit.com. Hooshmand, who says she is not associated with CrossFit, reviewed the medical literature and concluded that rhabdo is not exclusive to CrossFit: “The populations affected by exercise-induced Rhabdo and reported in peer-reviewed journal articles and case studies range anywhere from teenage athletes to professional football players, fire-fighters, Army and Air Force personnel, bodybuilders and swimmers. Therefore, it appears that exercise-induced Rhabdo can afflict individuals in almost any form of intense exercise.”

Hooshmand also ran the available numbers to see whether claims about the rate of rhabdo incidents in CrossFit, Robertson’s or otherwise, have any evidence to support them. “Let’s do the math,” she writes, calculating from the known cases of rhabdo over the first 10 years of CrossFit’s existence. “[It] equates to less than 1 case per year, accounting for 0.00000036% of the U.S. population averaged over those 10 years.” Hooshmand also says the Centers for Disease Control and Prevention does not appear to be keeping stats on rhabdo, “suggesting the condition is either extremely rare or poorly documented.”

Dr. Leon Chang, an MD specializing in anesthesiology, is a co-owner of CrossFit Elysium in San Diego. Chang has a unique point of view on the controversy, given his combination of CrossFit knowledge and time spent in the hospital helping to treat victims of the disorder. “As far as rhabdo, I am mildly concerned as an owner,” he says. “In general, rhabdo is very rare in the CrossFit population. If you look at youth sports, like high school football, distance running and such, you’ll see there are far more cases of rhabdo or generalized injury from over-exertion in those activities compared to CrossFit. Unfortunately, due to CrossFit’s reputation for intensity, coupled with a laissez-faire attitude on the part of some in the community and playful jokes like Pukey the Clown and Uncle Rhabdo, cases of rhabdo in CrossFit get blown out of proportion.”

Chang says exercise-induced rhabdo bears little resemblance to the condition caused by something like a car crash. “I have seen and taken care of many patients in the hospital with rhabdo,” Chang says. “When serious, it truly is a life-threatening condition—the cases I’ve seen in the hospital make the CrossFit examples pale by comparison.”

Chang disagrees with the fundamental point that critics like Robertson try to make—that unknowing newbies entering a CrossFit box are a high risk. “The new athlete is essentially not at risk for rhabdo. In a nutshell, they simply are incapable of pushing themselves hard enough to cause muscle breakdown and real injury. Lack of cardiovascular conditioning, strength and mental willpower will kick in and cause them to slow down way before they are at risk for rhabdo, which is a protective mechanism. Similarly, an athlete who has ‘trained up’ appropriately has developed their capacity in step-wise fashion: They can handle what they can do, because they practiced and developed the ability to get to where they are. So they’re a safe population as well.”

“This is a recipe for rhabdo.”

Who is at risk then? Which athletes participating in CrossFit are potentially in danger? The answer, according to Chang, is former athletes who are out of shape. He says, “An ex-military individual or former CrossFitter are perfect examples. These people have pushed hard before and they have the mental toughness to keep going when their bodies say stop. Unfortunately, they are physically de-conditioned and no longer equipped to handle such high intensity. This is a recipe for rhabdo, and for those people, we watch them very carefully, and make sure they don’t push too hard on their first few workouts.”

This may have been the case in the Iowa Hawkeyes football episode. As the Cedar Rapids Gazette reported, the Squat session (which apparently was followed by Sled Drags), was one of the first workouts in the off-season training schedule, right after winter break. As a father of one of the hospitalized football players acknowledged in a press conference, concerning how much training his son had performed over the break, “I could tell you he didn’t do anything except eat a lot and lie around, and then this was kind of the first day back.”

John Welbourne is a nine-year veteran of the NFL and creator of CrossFit Football. He commented on the Iowa football affair in a blog post, suggesting that a number of factors may have contributed to the incident in which so many athletes suffered rhabdo at once—but most likely it was just too much, too soon for players who showed up out of shape. “Had [the coaches] prepared their athletes for a workout consisting of 100 Back Squats at 240 pounds and a 100-Yard Sled Drag done as quick as possible? I guess not, as rhabdo usually follows a dramatic increase in volume. The problem is, these athletes might not have been ready to handle this workload, and the coaches should have realized it. Many times as a coach you design something that looks great on paper only to change it dramatically once the workout starts.”

Welbourne also openly wondered whether the workout was on a Wednesday, Thursday or Friday morning—following a “dollar drink night,” which is not uncommon in a university town at the beginning of the semester. A night of drinking could have set the stage for rhabdo via dehydration, he wrote. (Jan. 20, 2011 was a Thursday.)

Keys to prevention

Whether it’s a first week of CrossFit training or an early season football practice, how can athletes and coaches reduce the risk of rhabdomyolysis?

Gradual exposure to high-intensity training. In a 2005 CrossFit Journal article, Glassman explored the nature of the five CrossFit-induced rhabdo cases that had been reported to date. To reduce risk, Glassman advocated “On-Ramp” beginner programs for anyone new to CrossFit, even those coming from more standard physical fitness programs where workout intensity was relatively low. “Elite CrossFitters are performing 18,000 foot-pounds of work per minute for three or four minutes (that’s nearly half of one horsepower!),” Glassman wrote. “This is what our top tier athletes are doing in workouts like ‘Fran.’ Without deliberately training for maximum expression of effective work against a wide-ranging time domain, it is virtually impossible to deliver power output as high as our athletes do.”

“Hydrate or Die.” In an article written for the CrossFit Journal, Eugene Allen enumerates some of the other known causes for inducing rhabdo, including heavy alcohol consumption. Allen suggests dehydration is the most prominent threat for athletes. For the athlete, hydrating before a workout, especially in hot weather, is a preventative measure. “The Camelbak tag line ‘Hydrate or die’ is more meaningful in light of some understanding of rhabdo,” he says.

Beware of eccentric movements. Dr. Chang says that with respect to rhabdo, an emphasis on eccentric movements, with high repetitions, is particularly dangerous. “Any movement with a pronounced eccentric component can potentially cause rhabdo, out of proportion when compared to other movements,” he says. “An eccentric movement is when the muscle is ‘loaded’ and under tension but is not contracting. So for example, when one deadlifts, the pull from the floor is concentric. Once at the top, lowering the weight under control to the ground is an eccentric load. Hamstrings lengthen, back muscles tighten up, but no contraction occurs.” Some exercises have a pronounced eccentric phase, and a good CrossFit coach will be aware of the danger and temper the volume levels for beginners.

“The classic offenders are Kettlebell Swings and Jumping Pull-Ups,” Chang adds. “In the Kettlebell Swing, controlling the bell on the way down represents a very long, loaded eccentric phase. For the Jumping Pull-Up, what often happens is the individual does the Pull-Up, but then slowly lowers themselves back down, which represents eccentric work for the forearms and lats.”

T.J. Murphy is a veteran journalist, CrossFitter, and author of the best-selling book Inside the Box: How CrossFit® Shredded the Rules, Stripped Down the Gym, and Rebuilt My Body. Inside the Box is now available in your local bookstore, CrossFit gym, and from these online retailers. Please order Inside the Box today.Inside the Box a book about CrossFit by T.J. Murphy ITB 72dpi 400x600

What Happened When a 300-Pounder Tried CrossFit

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Photo by Jay Kay (jayknickerbockerphotography.com)

(originally published on Stack.com)

The first time he walked into a CrossFit box about a year ago, 30-year-old Travis Brumbaugh was a chain-smoking sales manager whose weight hovered around 300 pounds. “I was doing all of the wrong things,” he says.

Brumbaugh wore size 44 pants and frequently worked 12-hour days. To counter the stress of his job, he ate pretty much anything and everything, and his weight skyrocketed as a result. After trying and failing numerous diets, he was on pace to become one of the 25.8 million Americans suffering from Type 2 Diabetes. And though he’d recently trimmed down to about 285 pounds thanks to a set of P90X DVDs, he’d fallen off the wagon and his weight was climbing back up when, in a last-ditch effort, he joined CrossFit 428 in Tampa, Fla.

With a body type that could be categorized as morbidly obese, Brumbaugh was not even close to being prepared to handle the intense workouts performed by elite athletes at the CrossFit Games. Trainer Hope Keddington knew she’d have to scale back the movements and workouts to a level Brumbaugh could safely handle. “He was very overweight and he wanted to come in every day,” Keddington says. “I tend to be blunt. I told him, ‘If you can do it, I am all for it. But it’s going to be hard.’”

Keddington, who coached the 5:30 a.m. class, was an Olympic lifter in college, and she had seen many newcomers set unrealistic goals, grow frustrated and give up. She convinced Brumbaugh to try a three-days-per-week approach, which would give him sufficient time to recover from each workout. The workouts were challenging, and Brumbaugh started off slowly, but he kept coming back consistently. He liked Keddington’s coaching and the team atmosphere of the gym and its members. Eventually he saw results.

“It felt like an overnight thing,” Brumbaugh says. “In the fourth month, it was like the fat just started falling off me.”

After 10 months, Brumbaugh had lost over 60 pounds and burned 10 inches off his waist size, from 44 to 34. Attending the 5 a.m. classes, he upped his attendance to four, and eventually to five days per week. Today, “he only misses workouts on the rarest of occasions,” Keddington says. “He’s the poster child for what CrossFit can do for you.”

Last November, Brumbaugh competed in the entry level section of an inter-gym competition. He hit a personal record on the Snatch, lifting 135 pounds, as well as a PR for Pull-Ups. “He did 10 of them,” Keddington says proudly. “All unbroken.”

(Read the rest of the story on Stack.com)

T.J. Murphy is a veteran journalist, CrossFitter, and author of the best-selling book Inside the Box: How CrossFit® Shredded the Rules, Stripped Down the Gym, and Rebuilt My Body. Inside the Box is now available in your local bookstore, CrossFit gym, and from these online retailers. Please order Inside the Box today.Inside the Box a book about CrossFit by T.J. Murphy ITB 72dpi 400x600

How to Find a Great CrossFit Gym

Annie Sakamoto pushing the sled in the 2011 Reebok CrossFit Games chipper.

Annie Sakamoto pushing the sled in the 2011 Reebok CrossFit Games chipper.

Getting the most out of CrossFit generally requires two things: One, true commitment and dedication to the program, and Two, being able to apply that at a gym where the coaches know what they’re doing.

The ever-lucid and methodical Dr. Leon Chang at CrossFit Elysium has 10 suggestions on how to zero in on a great gym.

How to Do 30 Ironmans in 30 Days: A Sports Psych Technique

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Wayne Kurtz finishing his impossible journey: 30 Ironmans in 30 days.

I recently spent some time on the phone with ultra-triathlete Wayne Kurtz. Kurtz told me about his remarkable journey earlier this year, being one of 8 triathletes to set a world record: They did 30 Ironmans in 30 consecutive days. What intrigues me most about a story like Wayne’s, or a story of how a Navy SEAL makes it through Hell Week at BUD/s, is the use of segmenting: A technique in which an athlete or trainee “eats the elephant” by focusing on one bite at a time. It takes some real psychology power (I think anyway) to block out the enormity of a long, difficult effort — and competing in the CrossFit Games is a good example —and just focus on the task of the moment.

I’ve asked Kurtz to put together some tips on how he employs his discipline. I’ll post them here in a few days.

The Diagnostic Power of a Squat

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This is Jill Ketchum, one of my fellow runner/CrossFitters at CrossFit Elysium. She has become an unbreakable runner.

Here’s a memory: When I was in high school I used to squat with heavy weights two or three times per week. It was part of my preparation for high school football. But the memory is a slightly ugly one, because these are some defining characteristics of my technique:

1. My knees collapsed inward.

2. It was more like a quarter-squat than a half-squat, and surely not a full squat.

3. I doubt I did anything to brace my spine with a tight core.

And I’m sure there were other technique flaws as well. Decades later and thanks to CrossFit coaches, I not only learned how to squat safely, but effectively, and I’ve learned first-hand that it is a powerful full-body functional exercise that has tremendous positive impact. In a story I wrote recently for Stack.com, I talk about some of the value I’ve picked up on.

 

Free Entry to a Spartan Race up for grabs

Coverage of the Spartan Race World Champs airs on NBC on Oct. 19th.

Coverage of the Spartan Race World Champs airs on NBC on Oct. 19th.

First, the good folks at Spartan Race have given Inside the Box a free race entry to give away in a drawing. If you’d like to win an entry to any open heat in a 2013-2014 Spartan Race (in the continental USA), send me an email with your name and info and I’ll put you in the drawing.  I’ll do the drawing on October 19, the date that the Spartan Race World Champs will be aired.

Some quick remarks on the rise of events like the Spartan Race:

A few months ago I was talking with a CrossFit box owner in San Francisco about his fitness.  He told me he had registered for a mountain biking race. “I want to get out there and do something with all of this training,” he told me. The translation was: I’ve been hammering all of these WODs for months on end. I want to see what I can do with it.

One of the grand misconceptions of CrossFit (in my view anyway) is that CrossFit is so general that it doesn’t prepare you for a specific sport competition. It may not prepare you to win a specific sports event (save a CrossFit competition), but there’s a lot of things out there that you can enter and do pretty well at, especially if you tweak the programming a bit.

Indeed, CrossFit is a general strength and conditioning program. However, the original design of CrossFit is meant to include participation in competitions outside of the box. That CrossFit — including layers of nutrition, strength & conditioning, gymnastics and Olympic Lifting–is a foundation for the top of the pyramid, which is “Sport/Specialty.”

The CrossFit pyramid.

The CrossFit pyramid.

CrossFit Games and “Throwdowns” and the like are great, but as many CrossFitters know and show, one of the great things about the program is that it prepares you to jump in a lot of things. This Saturday I’m planning on going to watch some of my fellow members at Amity CrossFit jump in a local Olympic Lifting meet. Olympic lifting meets, power lifting competitions, marathons, triathlons–these are some of the more common outlets for the top-of-the-pyramid part of the CrossFit program.

But there’s been a match-made-in-heaven sort-of-thing when it comes to the rise of obstacle course races, like the Spartan Race series, which Outside Magazine named as the best of it’s kind. The appeal of CrossFit–a series of back-to-basics daily challenges and competitions that constitute an all-around development of mental strength and fitness–is on the same frequency that the Spartan events are tuned in to. Rather than just a pure point-to-point running race, races like the Spartan Race require a much fuller spectrum of athletic capacity, from strength, to agility, to being able to climb things, to jumping and landing. To braving barbed wire, rope climbing and flipping tractor tires.

So if you’re itching to get out of the gym and put your CrossFit powers to work, Spartan Race won’t need much tweaking of your programming. Their 2014 event schedule is seemingly unlimited. To see what it’s like be sure to tune in to NBC’s coverage of the the Spartan Race World Championships on October 19, a 90-minute special.

What CrossFit Is Really Like

Last night at Amity CrossFit. In the parking lot, owner/coach Aaron Ryan is working one-on-one with a young woman going through her first CrossFit class. I watched for about 10 minutes as he carefully taught her how to safely do a kettlebell swing, encouraging her gently the entire way.

Last night at Amity CrossFit. In the parking lot, owner/coach Aaron Ryan is working one-on-one with a young woman going through her first CrossFit class. I watched for about 10 minutes as he carefully taught her how to safely do a kettlebell swing, encouraging her gently the entire way.

There’s been a flurry of reporting on CrossFit in the last few weeks appearing on the likes of Salon.com, NPR’s website and Medium.com asserting a number of rather sensationally negative conclusions about the increasingly popular strength and conditioning program.

Assertions including: CrossFit reflects America’s militarism (??), CrossFit is racist and CrossFit has a “Dirty Little Secret” in regards to rhabdomylosis, a condition of muscle breakdown that has long been associated with CrossFit.

Eric Robertson, a physical therapist who wrote the rhabdo story for Medium, writes:

My prediction: in a few years, the peer-reviewed scientific literature will be ripe with articles about CrossFit and Rhabdomyolysis.

The number of CrossFit gyms has exploded to well over 4000 around the world, up from   the one that existed ten years ago. If there’s an epidemic of rhabdomylosis, where are the numbers? Robertson has no actual numbers in terms of cases. He has the story from a colleague who contracted it from a workout. Have CrossFitters had rhabdo? I’m sure. So have Ironman triathletes I imagine, but I don’t have actual numbers for either. I’ve been doing CrossFit for more than two years and I’ve done some pretty tough workouts. Yet I have never had rhabdo and have yet to hear about any of my cohorts getting rhabdo.

Furthermore, I am unaware of anyone dying from CrossFit-inflicted rhabdo. What do I know? Let’s take a relatively less intense exercise choice like cycling. In 2011, 677 Americans got killed in bike accidents and 38,000 got hurt. Oddly enough, I was one that was not accounted for as that was the year I took a bad spill on my mountain bike and have a scar on my forehead to remind me. The total cost of injury and death in cycling cost $4 billion per year, according to bicyclinginfo.org.

I love riding a bike, but there’s a risk. There’s also a risk in running: 82% of runners come down with at least one injury per year.

Then there’s the cost of not exercising. A number for Robertson to consider within his argument: 25.8 million. That’s the number of American children and adults who we know have Type-2 diabetes. That’s 8.3 percent of the population that could profoundly benefit from an exercise and diet regimen. Without diet and exercise they face a growing risk of other chronic diseases. Does it have to be CrossFit? Of course not. But what CrossFit does offer is a supportive atmosphere, education and coaching to help a person get there. It’s hard, but it’s remarkably fast and effective. It is for everyone? Nothing is for everyone. But a lot of people like it.  And as far as the risk of rhabdo,  I have yet to meet someone who has suffered from rhabdo. I have met a growing number of people who have beat back obesity by joining and participating in a CrossFit program.

Irene Mejia started CrossFit when she was 405 pounds. Not only has she remade herself in terms of health and fitness, she's closing in on working out at her 100th different CF box.

Irene Mejia started CrossFit when she was 405 pounds. Not only has she remade herself in terms of health and fitness, she’s closing in on working out at her 100th different CF box. To my knowledge, she hasn’t had rhabdo. But there’s no doubt she’s drawn some value from CrossFit. Mejia has more widespread knowledge than I do about what’s really going on in CrossFit. Robertson should talk to her before he writes another warning about the program.

Another thing that irks me is when someone like Robertson writes a story without actually stepping into a CrossFit gym. He does some Googling and talks to his friend. Why didn’t he stop in one and talk to the coaches and athletes to get some on-the-ground reporting? If he did he didn’t mention it.

For those that wonder what a CrossFit gym is really like, let me say this: There are all sorts, there are good gyms and there are bad gyms, but it’s worth finding a good one and trying it out if you’re interested in optimum health and fitness.

This is what one sort of gym is really like. Right now I’m a member of Amity CrossFit, a gym that is owned and operated by Aaron Ryan. Ryan employs two coaches, Zack Height and Liz Spragens. The gym, on El Camino Real, is one of Palo Alto’s remnants from the WWII era, a corrugated metal structure called a Quonset hut. As fellow member Chris Polonchek and agreed on a couple weeks back, it’s (for us anyway) it’s an oasis in the austere world of Palo Alto/Silicon Valley.

It’s quintessential CrossFit: an old school gym with basic equipment and good coaches. Everyone is friendly. The coaches are knowledgeable and–unlike the popular image of CrossFit–they don’t act like drill sergeants. In fact, they coach newcomers to ease slowly into the program. “It’s funny,” Ryan said to me the other day. “You often get people starting the program that want workouts that will make them really sore. We tell them it’s much better to adapt progressively into the training. We try to slow them down. Getting really sore in your first week of training isn’t going to help you toward your goal.”

Ryan, Height and Spragens are all quite calm with their coaching. They don’t yell. They watch their clients perform the movements and give them cues to improve. They encourage them in the conditioning workouts. They answer questions about technique and nutrition. They have the extreme challenge of helping me with my rather sad Olympic lifting efforts.

Right now, the gym is participating in the Whole Life Challenge, an 8-week program that challenges participants to improve their diets, build an exercise habit and attend to things like hydration and proper sleep. It started back in early September. It has worked almost too well for me. My fiancé said this to me a few days ago: “You’re a totally different person. I like you better. You can’t go back to eating sugar.” In other words, I may have had my last Oreo cookie. I’ve lost seven pounds, am sleeping better, and at the end of the challenge I’ll see how much I’ve improved as far as performance fitness.

Liz Spragins coaching the 6:30 class. We had about 10 show for the 5:30. No one got rhabdo.

Liz Spragens coaching the 6:30 class. We had about 10 show for the 5:30. No one got rhabdo.

I’m also going to be taking a blood test at the end of the challenge to see how much I’ve improved my cholesterol profile, which–no doubt because I let my diet slip in the last year–was alarming enough that the doctor said I should get proactive about things.

So that’s my personal anecdotal story about why alarmists like Robertson should look a little deeper before making predictions. And Robertson should drop into a gym like Amity  CrossFit or CrossFit Elysium and talk to a few people. He might expand his perceptions.

T.J. Murphy is a veteran journalist, CrossFitter, and author of the best-selling book Inside the Box: How CrossFit® Shredded the Rules, Stripped Down the Gym, and Rebuilt My Body. Inside the Box is now available in your local bookstore, CrossFit gym, and from these online retailers. Please order Inside the Box today.Inside the Box a book about CrossFit by T.J. Murphy ITB 72dpi 400x600