Rhabdomyolysis Case Study

Author/s

Kat Brock, Lindsay Matijevich, Evan Scher, and Katy Wiggins from Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Patient Characteristics

Patient is a 55 year old female that reports to your clinic with complaints of low back pain and leg pain. She is a full time teacher at a local high school. She has history of hypertension that is now controlled with diet and exercise but other comorbidities have not been found. The patient disclosed that she had the flu last week but has not been tested or had a diagnosis confirmed. She has had no other treatment prior to this therapy session.

Examination

Patient complains of back pain that is making it difficult to sit for long periods at work. She reports bilateral tenderness over her low back and generalized weakness of the lower extremities. She states that she can't afford to miss anymore school so it's important that she get her pain resolved as quickly as possible. She says that she is still fatigued but attributes that to being sick and still not being fully recovered. She also mentions during the evaluation that she felt extremely hot and clammy. Her temperature was taken and measured 101. 3°F. When asked of any other symptoms she has noticed, she remarks that her urine has been unusually dark the past week and almost looks bloody. She also states that she has been experiencing some mild shortness of breath that has been getting worse the past couple days. Again this was attributed to being sick, dehydrated, and deconditioned.

Patient has a history of hypertension but has been able to control it with diet and exercise and has not taken medication for her high blood pressure in 5 years. Her father also has a history of congestive heart failure and type 2 diabetes. She had her gallbladder removed 7 years ago but has had no other major surgeries. She is currently not taking any prescription medications regularly but has been taking over the counter Aleve® for her back and leg pain.

Patient reported outcome measures were used during the evaluation in this case study. The patient completed a Visual Analog Scale (VAS), Lower Extremity Functional Scale (LEFS), and a Oswestry Disability Index (ODI). On the VAS, the patient reported that her pain was a 2/10 at best, a 6/10 at worst, and was currently at a pain level of 3/10. On the LEFS, the patient scored a 30/80 putting her at 37% of her maximum function. On the ODI, the patient scored a 33/50 putting her at 66% disability in the catergory of "crippling back pain." 

Image 1: Urine from a person with rhabdomyolysis showing the characteristic brown discoloration as a result of myoglobinuria

• Objective : Physical Examination Tests and Measures

Clinical Impression

Our clinical impression at first glance would be that the patient is still suffering from flu like symptoms. Another possible diagnosis could be sciatica since her pain is presenting in her low back and legs. It would be critical to ask the patient to describe the type of pain that she is experiencing. Given that the patient’s pain is bilateral and she is having blood in her urine leads us to suspect that her pain is from systemic origins. A number of kidney disorders can cause blood to be present in the urine including urinary tract infections, kidney infections, kidney stones, glomerulonephritis, inherited disorders such as sickle cell anemia, or advanced stages of kidney cancer. Because this patient had no complaints of painful urination, flank pain, no history of cancer or inherited disorders, and no direct trauma to the kidneys lead us to suspect rhabdomyolysis caused by an infection.

Summarization of Examination Findings

With a working diagnosis of infectious rhabdomyolysis the patient would be referred out to a physician for immediate medical treatment. 

Intervention

The treatment of rhabdomyolysis is primarily directed at preserving renal function. Intravenous (IV) hydration must be initiated as early as possible.

Once patients have completed initial medical management, they should undergo physical therapy rehabilitation to regain full range of motion (ROM), muscle strength, and full function before progressing back to full physical activity. There is no set protocol of how to treat a patient with rhabdomyolysis. Each treatment should be centered to fit the patient’s individual needs. Below is an example of a treatment presented in the Journal of Orthopedic and Sports Physical Therapy in 2003. This rehabilitation program was used for the diagnosis of acute exertional rhabdomyolysis (AER) secondary to intense push-up training.

TABLE 1. Randall et al’s19 rehabilitation program for patients with acute exertional rhabdomyolysis secondary to intense push-up training.

Phase 1. Active and gentle passive range of motion (ROM) of the shoulder and elbow within limits of pain.

Phase 2. Initiated once active ROM is normal. Upper body ergometer at low intensity for 5 minutes progressing daily until this workload can be maintained for 15 minutes.

Phase 3. Initiated once the patient can maintain 15 minutes on the upper body ergometer without discomfort, change in technique, or muscle soreness 24 hours postexercise. Progress to isotonic weight training with light weights for specific muscle weakness (eg, elbow extension for triceps), modified pushups, and bench press. Modified pushups are performed daily on an incline (such as against a wall) and progressed as tolerated to tabletop, stool, and floor (without modification).

Phase 4. Initiated once patient progresses to push-ups without modification. Patient is allowed to resume normal exercise routine with the restriction of only performing 1 set of push-ups in any 24- hour period. This restriction is maintained until the patient is able to perform at their preinjury number of push-ups without sequelae such as muscle soreness or loss of normal ROM.

Outcomes

Typically patient will return to normal activities within a couple weeks to a few months after treatment depending on the severity. The earlier the patient is able to begin treatment including IV fluids or possibly dialysis to reduce the risk of kidney damage the better their prognosis. Patients that are not treated quickly may go into renal failure, but is rarely fatal.  Some patients may have residual muscle pain or fatigue that can be addressed with physical therapy intervention.  For the case described above physical therapy can be beneficial for the patient if she continues to have lingering back and leg pain after her initial treatment. The protocol listed above was designed for exertional rhabdomyolysis of the shoulders, but the core concepts can be redesigned to fit other patients with residual muscle pain. (5) A gradual approach will be beneficial to patients that present with muscle pain after an episode of rhabdomyolysis as to return their body's to the demands of normal activities without risking another breakdown of muscles.

Discussion

Physical therapists are likely to be one of the first healthcare professionals to see patients that present with rhabdomyolysis as their underlying cause due to the muscular origin of their pain. Being able to identify the red flags, such as dark urine, is vital in the diagnosis and referral of the patient to get immediate treatment and therefore decreasing the risk of severe kidney damage. Patients may be hesitant to discuss changes they have noticed in their urine without the therapist specifically asking about it. Taking an accurate history from the patient can lead to asking the correct questions to determine a diagnosis. It is also important to know the etiology of the disease that may be presenting. Rhabdomyolysis has several known causes with the most common being infectious disease, such as influenza, and over exertion during exercise. If a patient comes to the clinic with muscle pain or fatigue along with complaints of a cold or high intensity exercise recently, adding in a question about the color of their urine may prove to be pertinent in making the correct diagnosis.

Related Pages

MedlinePlus: www.nlm.nih.gov/medlineplus/ency/article/000473.htm

Physiopedia: www.physio-pedia.com/Rhabdomyolysis

Infectious vs Non-infectious Rhabdo (MedScape): www.medscape.com/viewarticle/433872

A case study (1995): cid.oxfordjournals.org/content/22/4/642.full.pdf

References

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