DISORDERS OF PROLONGED EXERTION Dr Chris … OF PROLONGED EXERTION Dr Chris Ellis M Sc, MRCGP, MFSEM...

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DISORDERSOFPROLONGEDEXERTION

DrChrisEllisMSc,MRCGP,MFSEMGeneral&SportsPractitioner,Kinlochleven.

WHWR“Inspiration”EveningPitfallsofUltra-EnduranceExercise

Stayingsafe-duringandafter.

Objectives=Awarenessof:Normal&Abnormalchanges:Biochemical,temperature&weight

Serious&Innocentcollapse:• Duringexercise– cardiac/other• Afterexercise- EAPH

Generalised&Localiseddisorders:• EAH• Rhabdomyolysis• Heatstroke

• Compartmentinjury• Stressfractures

“Wehavewon.”

AND THEN HE DIED!Pheidippides490 BC

Deaths in Great North Run may prompt review of advice for runners.Andrew Culf, Sports CorrespondentThe Guardian, Tuesday 20 September, 2005.

Postmortem examinations were being held yesterday to establish the cause of deaths of four men who died while taking part in the BUPA Great North Run, the world's largest half-marathon.The four, aged between 28 and 52, collapsed in separate incidents around the 13-mile course.

“It won’t happen to me.”

Marathon victim died from drinking too MUCH water.

London Evening Standard24 April 2007

A 22-year-old man died after completing his first London Marathon because he drank too much water.

SERIOUSCOLLAPSERuleofthumb:duringactivity.

• Rare,butpotentially lethal.• Usually cardiac– butmaybeanything.• Whencardiac,underlying causeusually governedbyage:

Under35years-Inheritedcardiacdefect.

Marc-VivienFoe(Deceased)

Over35years-Diseasedarteries

JimmyFixx(Deceased)

INNOCENTCOLLAPSE:EXERCISEASSOCIATEDPOSTURALHYPOTENSION(EAPH).Commonestcauseofpost-exertionalcollapse,over-treatedandunder-recognised.

COLLAPSE:RULEOFTHUMB

•CollapseshortlyafterfinishingtheraceorastageisusuallyEAPHifrunnerisotherwisewell.

•Collapsewhilerunning,considerablyafter,orwithothersymptoms,shouldbeconsideredserious

Features:•Shortlyafterstoppingactivity•Noothersymptoms•Rapidspontaneous recovery•Noactivetreatmentneeded, justletlieandobserve.

RACE NO. CK(<200). RACENO. CK(<200). RACENO. CK(<200).63 12,174 124 8,429 67 7,36542 4,756 135 30,243 126 29,837145 7,528 49 17,097 80 14,6037 8,357 48 9,276 78 14,95299 8,735 50 2,584 26 3,20954 5,536 44 3,897 37 9,90911 19,487 121 26,723 6 1,124108 11,485 27 14,773 71 50,3475 19,790 132 7,147 127 13,54756 3,902 40 13,169 84 3,501141 12,553 86 3,565 120 65,72422 10,066 34 17,695 103 68,852150 26,345 31 4,925 122 14,73890 6,346 75 15,029 55 13,86462 6,582 148 17,697 113 42,67094 7,711 130 2,354 21 27,277144 3,644 29 25,671 20 1,499118 7,648 128 6,371 1 6,624101 2,924 38 6,765 109 8,06041 9,171 2 2,800 81 132,64519 2,793 70 10,530 134 29,490111 5,257 67 7,365 79 19,31052 13,309

PHYSIOLOGICAL: RHABDOMYOLYSIS IS UNIVERSAL AND USUALLY INNOCENT.

Creatinine Kinase levels (IU/L) in 67 healthy WHWR 2009 finishers.Cuthill, Ellis & Panarelli.

WeightChanges– 2009?Normal&desirable.

Median Range Pvalue

PRE-RACEWEIGHT

76.6 52.6-100.8

POST-RACEWEIGHT

74.4 51.8-97.8 <0.0001

%DIFF

-2.9 -6.4-+1.6

PostWeightPreWeight

110

100

90

80

70

60

50

Pre- and post-weight weight of athletes

Understand that % weight loss is not the same as % dehydration, and why.

0

500

1000

1500

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2500

-8 -6 -4 -2 0 2

Totalperform

ancetim

e(m

inutes).

Bodyweightchange(%).

WHWR, 2009. SA Ironman Triathlon, 2001 & 2.

COMPARATIVE DATA FROM WHWR AND SA IRONMAN WEIGHT CHANGE v. PERFORMANCE.

Cuthill, Ellis, Panarelli & Sharwood.

WEIGHT LOSS: Statistically significant association with favourable performance.

WEIGHT LOSS: Protective against hyponatraemia (EAH).Noakes et al, Pooled results from multiple ultras.

TEMPERATURE: EXERTIONAL RISE IS COMMON, UN-NOTICED & USUALLY INNOCENT.

THIS IS NOT HEATSTROKE, THIS IS A NORMAL, BUT NOT UNIVERSAL, RESPONSE TO HEAT LOAD.

Byrne et al (2006). Data from Singapore 1/2M.

ABNORMALBIOCHEMISTRY:EXERCISEASSOCIATEDHYPONATRAEMIA(EAH).

DavidRogers(Deceased),London Marathon, 2007

•EAH is low blood sodium.Sodium < 135.Cause is TOO much fluid, NOT lack of sodium.

•EAH symptoms. Mild: (sodium > 130).Severe: (sodium < 130)Confusion, fits, coma, death, others.

•EAH is real. Boston marathon study 13% runners, 0.5% critical. 9 known deaths worldwide. 5 known cases in WHWR since 2005.

•EAH risk factors. Drinking more than need, weight gain, female, slow pace, over 4 hour event, anti-inflammatory medication (NSAIDs).

•EAH is substantially avoidable.Drink by thirst. Avoid NSAIDs. Weight monitor during race.

•EAH has low incidence in NZ and SA.Where “keeping ahead” with fluids and “maintaining weight” are no longer advocated.

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123

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153

WHWR, 2009.n=66

WSER, 2009.n=47

COMPARATIVE SODIUM LEVELS IN HEALTHY FINISHERS WHWR v. WSER, 2009.Cuthill, Ellis, Panarelli & Hew-Butler.

*

*Pre-race sodium, 131. NOT EAH.

WHWR, 2009.(from 66 finishers tested.)

•Asymptomatic Hyponatraemia (EAH) - Nil.•Asymptomatic Hypernatraemia - 4.

WSER, 2009.(from 47 finishers tested.)

•Asymptomatic Hyponatraemia (EAH) - 19.•Asymptomatic Hypernatraemia - Nil.

• Generalisedmusclebreakdownandliberationofcontentsintobodyisuniversalandusuallyinnocent.

• Rhabdo symptoms.Musclepain.Darkurine.Lackofurine.Unwell.Weightgain.Vomiting.

• Rhabdo complications.Kidney (renal)failure(ARF),clottingfailure,others,death.

• Abnormalrhabdo isreal.TwocasesofARFfromWHWRsince2005.Bothrecovered,butnotguaranteed.

• Rhabdo prevention.LesspreventablethanEAH.Anti-inflammatories andviralillness areriskfactors.Suspectearlytominimise complications.Report:chocolateorreducedurine&excessivemusclepains, protractedvomiting,weightgain.

EXERTIONALHEATSTROKEElevationofCOREtemperatureabove40degrees,PLUSbrainimpairment.

• ExertionalHeatstrokeisNOTsameas“hot”.Exercisecancausethecoretemperaturetorisewithoutsymptomsorsignificance.

• ExertionalHeatstrokeisrare.NotseensofarinWHWR.

• ExertionalHeatstrokesymptomsareinitiallyvague.Non-specific confusion/lack ofwell-being.

Mortality,onceestablished, ishigh.

• CausesofExertionalHeatstrokecauses:Abnormaloverproduction ofheatbymuscleswithwhichbody can’tdeal.

Acombinationof,exercise,inheriteddisposition andunknown trigger.

• Exertionalheatstrokeprevention.Disposition ifprevious severe“heatreaction”toAnaestheticorotherprescribedorstreetdrugs.

Highsuspicion needed.Treatearlyandaggressivelyandacceptsomepeopletreatedunnecessarily.

ACUTECOMPARTMENTSYNDROME

Localised swellingofmusclegroup,usuallyofleg,withinenclosedsinew(fascia),followinginjuryoroveruseandmaybeassociatedwithconstrictingbandageorplastercast.

This is an emergency and requires urgent surgical decompression.

SITE %OFTOTAL

TIBIA 55

METATARSALS 23

FIBULA 14

NeckofFemur 4

ShaftofFemur 2

Pubicrami 2

Sacrum 0.1

Navicular

Cuboid

Patella

Sesamoids

Calcaneum

RUNNING INDUCED STRESS FRACTURES.Noakes T. (Lore of Running.)

Soft tissue infection(“cellulitis”).

Blister

CONCLUSIONS

•Read and learn the guidelines (runners & crew).

•Drink by thirst.

•Avoid NSAIDs.

•Monitor weight.

•Heat exhaustion doesn’t exist.

•Diagnose dehydration cautiously.

•Take guidelines (& urine) if need medical help.

•Insist on blood tests.

•No iv fluids without first measuring sodium.

THANK YOU & QUESTIONS