Rhabdomyolysis: Difference between revisions

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== Definition/Description<br>  ==
== Definition/Description   ==
[[File:RhabdoUrine.jpeg|right|frameless]]
Rhabdomyolysis is a serious condition caused by [[muscle]] injury. Rhabdomyolysis is serious and can be life-threatening<ref name=":0">Health Direct [https://www.healthdirect.gov.au/rhabdomyolysis Rhabdomyolysis] Available: https://www.healthdirect.gov.au/rhabdomyolysis (accessed 17.9.2021)</ref>.<span style="">&nbsp;</span>   


<span> Rhabdomyolysis is defined as a clinical and biochemical syndrome resulting from skeletal muscle injury that alters the integrity of the muscle cell membrane sufficiently to allow the release of the muscle cell content into the plasma.<ref name="S&S">Brudvig T, Fitzgerald P. Identification of Signs and Symptoms of Acute Exertional Rhabdomyolysis in Athletes: A Guide for the Practitioner. Strength &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Conditioning Journal (Allen Press) [serial online]. February 2007;29(1):10-14. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed March 23, 2014.</ref> </span>Due to the quick breakdown of the skeletal muscle there is a big accumulation of the breakdown products which can cause renal failure.  
* The etiology of rhabdomyolysis can be classified as: nontraumatic eg infections ; or traumatic, traumatic rhabdomyolysis are crush syndrome from accidents, earthquakes, and other natural and manufactured disasters<ref name=":2">Stanley M, Adigun R. [https://www.statpearls.com/articlelibrary/viewarticle/28509/ Rhabdomyolysis]. 2017 Available: https://www.statpearls.com/articlelibrary/viewarticle/28509/<nowiki/>(accessed 17.9.2021)</ref>.
* When muscle tissue gets seriously injured, it breaks down and dies, releasing its contents (including myoglobin) into the bloodstream. [[Myoglobin]] is toxic to the kidneys, and can lead to [[kidney]] complications, such as [[Chronic Kidney Disease|kidney failure]], and changes in balance of [[electrolytes]] in the [[Blood Physiology|blood]], which can lead to serious problems with the [[Heart Failure|heart]] and other organs<ref name=":0" />.
Image 1: [[Urine]] from a person with rhabdomyolysis showing the characteristic brown discoloration as a result of myoglobinuria


== Historical Background  ==
==Epidemiology==
Approximately 25,000 cases of rhabdomyolysis are reported each year in the USA.


The first known report of rhabdomyolysis occurred in Sicily in 1908 after an earthquake, this was also the first case of crush syndrome as well and was found in German military literature.<ref name="A" /><ref name="E">Efstratiadis G, Voulgaridou A, Nikiforou D, et al. Rhabdomyolysis updated. Hippokratia 2007; 11(3): 129-137.</ref><span style="">&nbsp;<ref name="V" />&nbsp;&nbsp;</span>While this was the first report there has been some speculation that there are references in the Bible about rhabdomyolysis during the Jews exodus from Egypt. It was described as a plague that occurred after a large intake of quail.<ref name="A">Huerta-Alardin AL, Varon J, Marik P. Bench-to-beside review: Rhabdomyolysis - an overview for clinicians. Critical Care 2005; 9: 158-169</ref>&nbsp;<ref name="V">Vanholder R, Mehmet S, Erek E, Lameire N. Rhabdomyolysis. Journal of the American Society of Nephrology 2000; 1553-1561.</ref><span style="">&nbsp;&nbsp;</span>A similar incident occurred in 1930 in the Baltic sea area where there was a large consumption of intoxicated fish.<ref name="E" /><span style="">&nbsp;&nbsp;</span>  
* The prevalence of acute kidney injury in rhabdomyolysis is about 5 to 30%<ref name=":2" />
* Eighty-five percent of victims of traumatic injuries develop rhabdomyolysis.<ref name="A">Huerta-Alardin AL, Varon J, Marik P. Bench-to-beside review: Rhabdomyolysis - an overview for clinicians. Critical Care 2005; 9: 158-169</ref><span style="">&nbsp;&nbsp;</span><span style="">&nbsp;</span>
* It is also suggested that victims of severe injury that develop rhabdomyolysis and later acute [[Renal Function Test (RFT)|renal]] failure have a mortality of 20%.<ref name="A" />  
* Rhabdomyolysis can occur at any age, but the majority of cases are seen in adults.
* Males, African-American race, obesity, age more than 60 are factors that demonstrate a higher incidence of rhabdomyolysis.
* The most common cause for rhabdomyolysis in children is infection(30%). <ref name=":2" />


=== '''<u></u>'''Military'''<u></u>'''  ===
==Pathophysiology==
[[Image:Rhabdomyolysis Patho.png|right|499x499px|Courtesy Of: Efstratiadis G, Voulgaridou A, Nikiforou D, et al. Rhabdomyolysis updated. Hippokratia 2007; 11(3): 129-137.|alt=|frameless]]


The focus of rhabdomyolysis really came about during World War II, especially during the bombing that occurred in London, where crush victims developed acute renal failure.<ref name="A" /><ref name="E" /><span style="">&nbsp;&nbsp;</span>Reports were also present during the Korean War as well as during Vietnam.<span style="">&nbsp; </span>During Vietnam the incidence actually decreased which is thought to be due to the faster evacuation techniques and improved fluid resuscitation to victims.<ref name="A" />  
Rhabdomyolysis occurs due to injury eg mechanical, chemical, toxins, poisons, burns. These injuries have a detrimental effect to the cell membranes throughout the body. When a cell membrane is damaged the breakdown releases organic and inorganic intracellular components eg potassium, myoglobin, lactic acid, purines, and phosphate which enter the circulation.<span style=""><ref name="V">Vanholder R, Mehmet S, Erek E, Lameire N. Rhabdomyolysis. Journal of the American Society of Nephrology 2000; 1553-1561.</ref> &nbsp;</span>


=== Natural Disasters'''<u>[[Image:Haiti.png|thumb|right|400x200px|Picture of rescue attempts in Haiti after the earthquake in January 2010]]<br></u>'''  ===
After the restoration of [[Blood Physiology|blood]] flow after the injury these components become toxic to the body and in most cases are life threatening, making rhabdomyolysis a medical emergency.<ref name="E">Efstratiadis G, Voulgaridou A, Nikiforou D, et al. Rhabdomyolysis updated. Hippokratia 2007; 11(3): 129-137.</ref> Myoglobin levels rise within hours of muscle damage, but can return to normal in 1-6 hours if continuous muscle injury is not present.<ref name="b">Bagley WH, Yang H, Shah KH. Rhabdomyolysis. Intern Emergency Medicine 2007; 2: 210-218</ref>


As seen through history the most common incidence of&nbsp;rhabdomyolysis occurs during natural disasters&nbsp;where there are less resources available to help trapped victims, making their time under rubble longer and increasing their chances of developing rhabdomyolysis.<span style="">&nbsp; </span>On August 17, 1999 in Marmara, a region of Turkey, an earthquake with a 7.4 magnitude devastated the area.<span style="">&nbsp; </span>This earthquake caused 17,480 deaths.<span style="">&nbsp; </span>Many victims were sent to hospitals; 9,843 patients were hospitalized with 425 of them dying.<span style="">&nbsp; </span>Of those 9,843 patients, 639 patients developed renal failure, this was 12% of the patients that were hospitalized.<span style="">&nbsp; </span>The victims average time spent under rubble was 11.7 hours.&nbsp;<ref name="A" />
Myoglobin is usually filtered through glomeruli (of the [[kidney]]<nowiki/>s) and reabsorbed in the proximal tubules by endocytosis, however when rhabdomyolysis occurs there is an excess of myoglobin, which overloads the proximal tubule cells ability to convert iron to ferritin, which then results in intracellular ferrihemate accumulation.<ref name="b" /> Since [[iron]] can donate and except electrons as well as having the ability to generate [[Free Radicals|free radicals]] the urine’s pH can lead to metabolic acidosis.<span style="">&nbsp; </span>This process puts oxidative stress and injury to the renal cells, which if untreated can lead to renal cell failure.<ref name="E" />  
 
=== Collapse of World Trade Center  ===
 
On September 11, 2001 in New York City the twin towers collapsed trapping many victims under rubble.<span style="">&nbsp; </span>Hospitals were prepared to have dialysis ready the days following the attacks to treat the many victims to prevent renal failure.<span style="">&nbsp; </span>Fortunately, very few victims had crush injuries and the only victim developed rhabdomyolysis was a 38 year-old police officer who had been trapped under rubble for 24 hours.<ref name="A" />
 
= '''Prevalence'''  =
 
Eighty-five percent of victims of traumatic injuries develop rhabdomyolysis.<ref name="A" /><span style="">&nbsp;&nbsp;</span>Of those, 10-50% of those patients will develop acute renal failure.<ref name="A" /><span style="">&nbsp;&nbsp;</span>It is also suggested that victims of severe injury that develop rhabdomyolysis and later acute renal failure have a mortality of 20%.<ref name="A" /> An estimated 26,000 cases of rhabdomyolysis are reported annually in the US.<ref>Harriston S. A review of rhabdomyolysis. Dimensions Of Critical Care Nursing: DCCN [serial online]. July 2004;23(4):155-161. Available from: MEDLINE, Ipswich, MA. Accessed March 23, 2014.</ref>&nbsp; Men have a slightly higher incidence of developing rhabdomyolysis than women.<ref name="b">Bagley WH, Yang H, Shah KH. Rhabdomyolysis. Intern Emergency Medicine 2007; 2: 210-218</ref>
 
<br>
 
= '''Prevalence in Children'''<ref name="qwe">Al-Ismaili Z, Piccioni M, Zappitelli M. Rhabdomyolysis: pathogenesis of renal injury and management. Pediatric Nephrology (Berlin, Germany) [serial online]. October 2011;26(10):1781-1788. Available from: MEDLINE, Ipswich, MA. Accessed March 23, 2014.</ref> =
 
Limited data exists on the prevalence of rhabdomyolysis in the pediatric population. The incidence of rhabdomyolysis in this population is estimated to be 0.26% (4:1,500 inpatient consultations) in a three year period at the University of California. Several small retrospective studies concluded that acute kidney injury rates in children admitted for rhabdomyolysis ranged from 42% to 50%, particularly when nongenetic chronic myopathies were evaluated. One other retrospective study included children with high CK after admission to the emergency department, excluding children with muscular disease, 5% developed acute kidney injury.<br><br>
 
= '''Pathophysiology'''  =
 
Rhabdomyolysis occurs due to injury whether it is mechanical, chemical, toxins, poisons, or burns, these injuries have a detrimental effect to the cell membranes throughout the body. When a cell membrane is damaged the breakdown or lysis releases organic and inorganic intracellular components such as potassium, myoglobin, lactic acid, purines, and phosphate which enter the circulation.<span style="">&nbsp;&nbsp;Exhaustive work of cells and stretching can increase sarcoplasmic influx of sodium, chloride, and water, which can result in swelling and auto destruction.<ref name="V" /> &nbsp;</span>After the restoration of blood flow after the injury these components become toxic to the body and in most cases are life threatening, making rhabdomyolysis a medical emergency.&nbsp;<ref name="E" />&nbsp;&nbsp;"Myoglobin levels rise within hours of muscle damage, but can return to normal in 1-6 hours if continuous muscle injury is not present."<ref name="b" /> [[Image:Rhabdomyolysis Patho.png|thumb|right|350x500px|Courtesy Of: Efstratiadis G, Voulgaridou A, Nikiforou D, et al. Rhabdomyolysis updated. Hippokratia 2007; 11(3): 129-137.]]
 
<br>
 
Myoglobin is usually filtered through glomeruli and reabsorbed in the proximal tubules by endocytosis, however when rhabdomyolysis occurs there is an excess of myoglobin, which overloads the proximal tubule cells ability to convert iron to ferritin, which then results in intracellular ferrihemate accumulation.<ref name="b" /><span style="">&nbsp; </span>Since iron can donate and except electrons as well as having the ability to generate free radicals the urine’s pH can lead to metabolic acidosis.<span style="">&nbsp; </span>This process puts oxidative stress and injury to the renal cells, which if untreated can lead to renal cell failure.<ref name="E" />
 
<br>  


When there is an excess of myoglobin the tubules are unable to reabsorb it.<ref name="E" /><ref name="V" /> Systemic vasoconstriction sets in which results in water reabsorption in renal tubules, which then increases myoglobin concentration in urine.<span style="">&nbsp; </span>This in turn causes formation of casts that obstruct renal tubules. Another contributing factor of cast formation is apoptosis that occurs in epithelial cells.<ref name="b" /><span style="">&nbsp; </span>This obstruction causes formation of free radicals from iron, which can lead to renal failure.<ref name="E" />  
When there is an excess of myoglobin the tubules are unable to reabsorb it.<ref name="E" /><ref name="V" /> Systemic vasoconstriction sets in which results in water reabsorption in renal tubules, which then increases myoglobin concentration in urine.<span style="">&nbsp; </span>This in turn causes formation of casts that obstruct renal tubules. Another contributing factor of cast formation is apoptosis that occurs in epithelial cells.<ref name="b" /><span style="">&nbsp; </span>This obstruction causes formation of free radicals from iron, which can lead to renal failure.<ref name="E" />  


<br>
Potassium is another byproduct of muscle lysis.<span style="">&nbsp; </span>With too much potassium in the circulation [[hyperkalemia]] can occur, which is life threatening, due to its cardiotoxicty effects.<ref name="E" /> Cardiac [[Heart Arrhythmias|arrhythmias]] can occur due to increased levels of potassium in the blood. In some cases, early death occurs due to [[Ventricular Fibrillation|ventricular fibrillation]].<ref name="F">Savage DCL, Forbes M. Idiopathic Rhabdomyolysis. Archieves of Disease in Childhood 1971; 26: 594-607</ref>  
 
Potassium is another byproduct of muscle lysis.<span style="">&nbsp; </span>If there is too much potassium in the circulation then hyperkalemia can occur which is life threatening, because of its cardiotoxicty effects, this is a medical emergency.<ref name="E" /><sup>&nbsp;</sup><span style="">&nbsp;&nbsp;</span>Cardiac arrhythmias can occur due to increased levels of potassium in the blood. In some cases, early death occurs due to ventricular fibrillation.<ref name="F">Savage DCL, Forbes M. Idiopathic Rhabdomyolysis. Archieves of Disease in Childhood 1971; 26: 594-607</ref><br>
 
<br>
 
Calcium accumulation in the muscles occurs in the early stages of rhabdomyolysis. &nbsp;Massive calcification of necrotic muscles can occur which can lead to hypercalcemia.<ref name="b" /> &nbsp;If hyperkalemia is present hypercalcemia can lead to cardiac arrhythmias, muscular contraction, or seizures.<ref name="V" />
 
= '''Causes'''  =
 
There are nine commonly reported categories of rhabdomyolysis. These categories include trauma, exertion, muscle hypoxia, genetic disorders, infections, body-temperature changes, metabolic and electrolyte disorders, drug and toxins, and idiopathic (sometimes recurrent) (Table 1). <ref name="gtr">Bosch X, Poch E, Grau J. Rhabdomyolysis and acute kidney injury. The New England Journal Of Medicine [serial online]. July 2, 2009;361(1):62-72. Available from: MEDLINE, Ipswich, MA. Accessed March 23, 2014.</ref><br>
 
<br>
 
[[Image:Causes chart.jpg|650x408px]]<br>
 
<ref name="gtr" /><br>
 
== Categories<br>  ==
 
=== <br>'''<u>Trauma</u>'''<br>  ===
 
<br>Crush syndrome results in a characteristic syndrome of rhabdomyolysis, inducing myoglobinuric ARF, also known as traumatic rhabdomyolysis. Traumatic rhabdomyolysis results from muscle reperfusion with subsequent secondary systemic effects. These are direct and indirect consequences of prolonged compression on the limbs. The continuous compression results in destruction of the muscle tissue and subsequent compromise of cell wall integrity and leakage of cellular contents.<br> <br>
 
Crush syndrome is fundamentally based on three criteria&nbsp;<ref name="crush">Dario G. Crush syndrome. Critical Care Medicine [serial online]. January 2005;33(1):S34-S41. Available from: Academic Search Premier, Ipswich, MA. Accessed March 23, 2014.</ref> <br>1. Involvement of muscle mass<br>2. Prolonged compression (usually 4-6 hrs, but possibly &lt;1 hr)<br>3. Compromised Circulation<br><br>
 
Renal and cardiac complications are specifically sensitive to the amount of pressure and the size of the muscle masses being compressed. This prolonged compression and entrapment of the muscle complex can lead to compartment syndrome or rhabdomyolysis. Rhabdomyolysis under these circumstances is potentially fatal. The syndrome is characterized by hypovolemic shock and hyper kalemia. This is commonly seen in natural disasters and other disasters such as earthquakes, war settings, vehicular accidents, and events involving pinning under objects. <ref name="crush" /><br><br>
 
==== '''Trauma Clinical Presentation''' <ref name="crush" /><br>  ====
 
The clinical presentation of crush syndrome is first based on the history of the event and a high index of suspicion. A compression of &gt; 1 hr is likely to result in a crush syndrome, but this has been seen in as little as 20 min. The physical presence of trauma or local sign of compression (erythema, ecchymosis, bullae, abrasion, etc) on a muscle mass should be evaluated. The absence of a pulse or a weak, thread pulse to the distal limb may indicate muscle swelling or compromised circulation. Patients with crush syndrome have historically been described as presenting with muscle weakness, malaise, and fever. These symptoms may underestimate the real dangers which lie in the cardiovascular effect as a result of electrolyte imbalances and renal failure.<br>
 
=== <br> <u>'''Exertional'''</u><br>  ===
 
Exercise-induced RM or exertional RM is the most frequent cause of RM-related hospitalization. Excessive, prolonged or repetitive exercise may overstretch the sarcoplasmic reticulum. This leads to an increase in Ca2+ leakage into muscle cells. The increase in Ca2+ activates sarcolemma (cell membrane)-degrading enzymes which cause an increase in sarcolemma permeability. With the sarcolemma more permeable, harmful proteins can escape and are released into the blood stream, potentially leading to renal failure, blood clotting and heart arrhythmias. <ref name="exert">Deyhle M, Kravitz L. research. Exertional Rhabdomyolysis: When Too Much Exercise Becomes Dangerous. IDEA Fitness Journal [serial online]. April 2013;10(4):16-18. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed March 23, 2014.</ref><br>
 
[[Image:Exertionalrhab.png]]<br>
 
Image Courtesy of Len Kravitz, PhD.
 
<br>
 
Causes/Risk factors for developing ERM: <ref name="exert" /><br>1. Intensive exercise or high-repetition exercise<br>2. Low baseline fitness levels<br>3. Early introduction of highly repetitive exercises like squats, push-ups and sit-ups. <br>4. Exertion beyond the point when fatigue would compel an individual<br>5. Exercising in hot/humid environments <br>6. Repetitive bouts of eccentric exercise<br>7. Hypokalemia (from excessive sweating)<br>8. Sickle-cell trait<br><br>
 
Landau and colleagues (2012) report examples of extreme exertion leading to ERM when exercisers attempted to do hundreds of push-ups in an afternoon or suffered from “squat jump syndrome” after being told to squat as low as possible and then jump as explosively as possible repeatedly until exhaustion. People who exercise regularly are less likely to develop the condition than their more sedentary counterparts. A sudden increase in intensity and duration of vigorous exercise, without proper training, may increase the likelihood of rhabdomyolysis.&nbsp;<ref name="spin">Parmar S, Chauhan B, DuBose J, Blake L. Rhabdomyolysis after spin class?. Journal Of Family Practice [serial online]. October 2012;61(10):584-586. Available from: Academic Search Premier, Ipswich, MA. Accessed March 23, 2014.</ref><ref name="rev">Khan F. Rhabdomyolysis: a review of the literature. The Netherlands Journal Of Medicine [serial online]. October 2009;67(9):272-283. Available from: MEDLINE, Ipswich, MA. Accessed March 23, 2014.</ref>
 
<br>''Vitamin D deficiency and exercise-induced rhabdomyolysis:''<br>Speculation has been made that subjects with low levels of vitamin D are at higher risk for developing exertional rhabdomyolysis.<ref>Glueck CJ, Conrad B. Severe Vitamin D Deficiency, Myopathy, and Rhabdomyolysis. North American Journal of Medical Sciences. 2013;5(8):494-495. doi:10.4103/1947-2714.117325.fckLRhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3690793/</ref>
 
''Recurrent exercise-induced rhabdomyolysis: ''<br>-Metabolic Myopathies<br>Metabolic myopathies are a common cause of recurrent rhabdomyolysis post exertion. Most commonly including McArdle disease, and Carnitine palmitoyltransferase deficiency. <br>(See sections on risk stratification and prevention of recurrent episodes)<ref>Miller M, M.D. (2017). Causes of rhabdomyolysis. [online] Uptodate.com. Available at: http://www.uptodate.com/contents/causes-of-rhabdomyolysis [Accessed 10 Mar. 2017].fckLRhttp://www.uptodate.com/contents/causes-of-rhabdomyolysis</ref><br>
 
<br>
 
==== Exertional Clinical Presentation<br>  ====
 
<br>Most cases of acute exertional rhabdomyolysis occur in the military. AER has also been reported in firefighting and law enforcement trainees, long-distance runners, individuals participating in weight training, and football players. However, very few cases of AER occur relative to the thousands of people training <ref name="S&S" /> Patients typically present with muscle pain, weakness and cramping and discolored urine. Some patients will also experience general malaise, visceral pain, swelling, muscle stiffness and tightness, fever, tachycardia, nausea, and vomiting.&nbsp;<ref name="spin" /> Patients will also present with significant loss of active range of motion. <ref name="S&S" /><br><br>
 
=== <u>'''Muscle Hypoxia (Prolonged Immobilization)'''</u><br>  ===
 
<br>Muscle hypoxia can result in rhabdomyolysis. The cause of this is secondary to limb compression by head or torso during prolonged immobilization or loss of consciousness.&nbsp;<ref name="gtr" /> Prolonged immobilization (anaesthesia, coma, drug or alcohol-induced unconsciousness) has been reported to cause rhabdomyolosis due to unrelieved pressure on gravity-dependent body parts. The primary mechanism is reperfusion of damaged tissue after a period of ischaemia, and the release of necrotic muscle material into the circulation after the pressure has been relieved. The most common positions leading to rhabdomyolosis were the lateral decubitis, lithotomy, sitting, knee-to-chest and prone position.&nbsp;<ref name="rev" />
 
The risk factors for position related rhabdomyolysis are identified as:&nbsp;<ref name="rev" />
 
1. Body weight more than 30% above ideal body weight<br>2. Duration of surgery more than five to six hours<br>3. Extracellular volume depletion<br>4. Pre-existing azotaemia<br>5. Diabetes<br>6. Hypertension<br>
 
==== <br>Muscle Hypoxia Clinical Presentation<br>  ====
 
<br>Subjects at the highest risk for muscle hypoxia induced rhabdomyolysis include super obese male patients with hypertension and diabetes who have been in prolonged immobilization.<ref name="morb">Bostanjian D, M.D., Anthone GJ, M.D., Hamoui N, M.D., Crookes PF, M.D. Rhabdomyolysis of gluteal muscles leading to renal failure: A potentially fatal complication of surgery in the morbidly obese. Obesity Surg. 2003;13(2):302-5. http://search.proquest.com/docview/821093760?accountid=6741. doi: http://dx.doi.org/10.1381/096089203764467261.</ref> This is commonly seen following long surgeries where the patient is immobilized on the operating table. In addition, other etiologic factors include a family history of muscle disease and consumption of certain drugs, notably taking a cholesterol lowering agent.<br>
 
<br>
 
=== <u>'''Genetic Defects'''</u><br>  ===
 
<br>Some genetic variations may predispose people to experience RM. Many of these variations result in a deficiency of enzymes important in ATP production or calcium handling.&nbsp;<ref name="exert" /> Abnormalities in glycogen or lipid metabolism result in a block of anaerobic glycolysis that predisposes to the loss of integrity of the sarcolemmal membrane and the liberation of myoglobin following exercise. <br><br>
 
The 3 most common inherited genetic alterations known to increase the risk of RM are:&nbsp;<ref name="exert" /> <br>
 
-McArdle’s disease<br> -Carnitine palmitoyltransferase II deficiency <br> -Myoadenylate deaminase deficiency <br>
 
Other genetic causes
 
<br> -Phosphorylase kinase<br> -Phosphofructokinase (Tarui’s disease)<br> -Phosphoglycerate mutase<br> -Phosphoglycerate kinase<br> -Lactate dehydrogenase<br> -Carnitine deficiency<br> -Myoadenylate deaminase deficiency<br> -Ducehnne’s muscular dystrophy<br> -Malignant hyperthermia<br><br>
 
These genetic factors may leave patients at an increased risk of developing RM because of a reduced ability to utilize glycogen to make ATP, a reduced ability to produce ATP from fat, and a reduced ability to re-form ATP during intense exercise. <br><br>
 
==== Genetic Clinical presentation<br>  ====
 
<br>Patients with genetic induced rhabdomyolysis will present with signs and symptoms of their inherited disease but will also present with secondary signs and symptoms of rhabdomyolysis. These secondary signs and symptoms include: swelling, stiffness and cramping, accompanied by weakness and loss of function in the involved muscle group(s). Nonspecific systemic symptoms such as malaise, fever, abdominal pain, and nausea and vomiting, may also be seen. Occasionally changes in mental status can occur.&nbsp;&nbsp;
 
<br>
 
=== <u>'''Infections'''</u><br>  ===
 
Viral and bacterial infections can cause rhabdomyolysis. Influenza, HIV, and coxasackievirus are the most common viral infections that are seen in rhabdomyolysis. The most common bacterial infections include legionella, Fracisella tularensis, streptococcus, and salmonella. Overall, the most recognized infections associated with rhabdomyolysis are Inluenza A and B and HIV&nbsp;<ref name="rev" /> The proposed mechanism for infection-induced rhabdomyolysis includes tissue hypoxia (caused by sepsis, hypoxia, dehydration, acidosis, electrolyte disturbances and hypophospataemia), direct bacterial invasion of the muscle, low oxidative glycolytic enzyme activity, activation of lysosomal enzymes, and mechanisms implicating endotoxins <ref name="rev" /><br>
 
==== Infections Clinical Presentation<br>  ====
 
The clinical presentation of infection induced rhabdomyolysis will be nonspecific and will vary depending on the underlying condition. Systemic signs and symptoms of rhabdomyolysis include tea-colored urine, fever, malaise, nausea, emesis, confusion, agaitation, delirium, and anuria. In ambiguous cases, clinical suspicion of rhabdomyolysis is confirmed by a positive urine or serum test for myoglobin.&nbsp;<ref name="rev" />
 
<br>
 
=== <u>'''Body-temperature changes'''</u><br>  ===
 
<br>Excessive heat, regardless of cause, may result in muscle damage leading to Rhabdomyolysis. Although more rare, excessive cold with or without hyperthermia can lead to Rhabdomyolysis as well due to its direct effect on muscle tissue. The maximum thermal temperature the human body can withstand before experiencing cellular destruction is 107.6 degrees F. Cellular destruction can begin at this temperature between 45 minutes to 8 hours. <ref name="rev" /><br>
 
Causes of excess heat that can induce Rhabdomyolysis<ref name="rev" /><br>1. Heat stroke<br>2. Neuroleptic malignant syndrome<br>3. Malignant hyperthermia.
 
<br>Shared features of malignant hyperthermia, exercise induced heat illness, and exertional rhabdomyolysis are hypermetabolic states that include a high demand for adenosine triphosphate, accelerated oxidative, chemical, and mechanical stress of muscle, and an uncontrolled increase in intracellular calcium. These processes overwhelm the normal cellular regulatory mechanisms and severe muscle injury and death occur in certain individuals. These similarities have raised the possibility that exercise induced heat illness, exertional rhabdomyolysis, and malignant hyperthermia are related syndromes triggered by different mechanisms <ref name="heat">Capacchione J, Muldoon S. The relationship between exertional heat illness, exertional rhabdomyolysis, and malignant hyperthermia. Anesthesia And Analgesia [serial online]. October 2009;109(4):1065-1069. Available from: MEDLINE, Ipswich, MA. Accessed March 23, 2014.</ref><br>
 
==== Body temperature changes Clinical Presentation<br>  ====
 
<br>Rhabdomyolysis induced from exercise induced heat illness will manifest symptoms of the heat illnesses themselves as well as the following rhabdomyolysis symptoms: muscle tenderness, tea-coloured urine, swelling, stiffness and cramping, accompanied by weakness. Systemic symptoms such as malaise, fever, abdominal pain, and nausea and vomiting, may also be seen. <ref name="rev" /><br><br>
 
=== <u>'''Metabolic and Electrolyte Disorders'''</u><br>  ===
 
<br>Rhabdomyolysis may be secondary to electrolyte abnormalities. These electrolyte abnormalities include hyponatraemia, hypernatraemia, hypokalaemia, and hypophosphataemia. The proposed mechanism for this is cell membrane disruption as a result of deranged sodium-potassium-ATPase pump function. In addition, rhabdomyolysis can be caused by endocrine abnormalities such as hyperthyroidism, hypothyroidism, diabetic ketoacidosis, and non-ketotic hyperosmolar diabetic coma.<ref name="rev" /><br><br>
 
==== Endocrine and Electrolyte Clinical Presentation<br><br>  ====
 
The clinical presentation of metabolic and electrolyte induced rhabdomyolysis will be nonspecific and vary depending on the underlying condition. The clinician should monitor systemic signs and symptoms to help determine if further testing is needed.<br><br>
 
=== <u>'''Drugs and Toxins'''</u><br>  ===
 
<br>Rhabdomyolysis may result from substance abuse, toxins, prescription and nonprescription medications. Substances that are commonly abused include ethanol, methanol, ethylene glycol, heroin, methadone, barbiturates, cocaine, caffeine, amphetamine, lysergic acid diethylamid, 3,4-methylenedioxymethamphetamine (MDMA, ecstasy), phencyclidine, benzodiasepines, and toluene (from glue sniffing).<ref name="rev" /> Rhabdomyolysis is a frequent consequence of illicit drug consumption that is not promoted by a single factor, but by a combination of several factors.<ref name="drug">Welte T, Bohnert M, Pollak S. Prevalence of rhabdomyolysis in drug deaths. Forensic Science International [serial online]. January 6, 2004;139(1):21-25. Available from: MEDLINE, Ipswich, MA. Accessed March 23, 2014.</ref> In acute poisoning, RM can be the result of multiple causing mechanisms. For instance, alcohol, cocaine, and possibly heroin act directly myotoxically. This mechanism should be distinguished from RM that develops secondarily, due to muscle ischemia during seizures or local muscle compression in comatose states. An increasing energy consumption can contribute to RM in some cases like hyperpyrexia in cocaine-induced RM. <ref name="acute">Janković S, Jović Stošić J, Vučinić S, Perković Vukčević N, Vuković Ercegović G. Causes of rhabdomyolysis in acute poisonings. Vojnosanitetski Pregled: Military Medical &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Pharmaceutical Journal Of Serbia &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Montenegro [serial online]. November 2013;70(11):1039-1045. Available from: Academic Search Premier, Ipswich, MA. Accessed March 23, 2014.</ref><br><br>
 
Main drugs and substances inducing Rhabdomyolysis<ref name="rev" /><br>-Statins <br>-Alcohol<br>-Barbiturates, benzodiazepines, and other sedatives and hypnotics<br>-Cocaine<br>-Heroin<br>-Ecstasy<br>-Stimulants used to treat ADHA (ie. Adderall, Ritalin, Vyvanse)<ref>Fda.gov. (2017). Stimulants Used to Treat Attention Deficit Hyperactivity Disorder (ADHD). [online] Available at: https://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm446139.htm [Accessed 12 Mar. 2017].</ref>
 
<br>
 
Rhabdomyolysis from alcohol is induced from a combination of immobilization, direct myotoxicity and electrolyte abnormalities (hypokalemia and hypophosphatemia). Cocaine induced rhabdomyolysis can occur through vasospasm with muscular ischemia, seizures, hyperpyrexia, coma with muscle compression, and direct myofibrilar damage. Statin-induced rhabdomyolysis may result from an unstable skeletal muscle cell membrane, the presence of abnormal prenylated protein causing an imbalance in intracellular protein messenger, and abnormal mitochondrial respiratory function caused by a coenzyme Q10 deficiency.<ref name="rev" /><br><br>
 
==== Drugs and Toxins Clnical Presentation<br><br>  ====
 
The clinical presentation of drug and toxin induced rhabdomyolysis can vary due to the nature and side effects of the drugs and toxins themselves. Clinicians must take note of the signs and symptoms of the drugs themselves as well as monitor for additional signs and symptoms of rhabdomyolysis. As previously mentioned, typical signs and symptoms of rhabdomyolysis include: tea-coloured urine, muscle tenderness, swelling, stiffness and cramping, accompanied by weakness and loss of function in the involved muscle group(s).<ref name="rev" /><br><br>
 
=== <u>'''Idiopathic'''</u>  ===
 
<br>In many cases the etiology of rhabdomyolysis cannot be identified. Some cases present with recurrent myoglobinuria and are termed idiopathic paroxysmal myoglbinuria (Meyer-Betz disease). Further studes are need to determine if these effects are from a genetic disease. <ref name="rev" />
 
<br>
 
=== '''<u>Other possible Causes<ref>Miller M, M.D. (2017). Causes of rhabdomyolysis. [online] Uptodate.com. Available at: http://www.uptodate.com/contents/causes-of-rhabdomyolysis [Accessed 10 Mar. 2017].</ref></u>'''<u></u> ===
 
'''<u></u>'''• Status asthmaticus<br>• Non-depolarizing muscle blocking agents to critically ill intensive care unit patients requiring mechanical ventilation<br>• Capillary leak syndrome<br>• Baclofen withdrawal<br>• Inflammatory myopathies – polymyositis, dermatomyositis<br>
 
= Risk Factors For Postoperative Rhabdomyolysis<ref name="press">Torres-villalobos G, Kimura E, M.D., Mosqueda JL, M.D., García-garcía E, MD, Domínguez-cherit G, MD, Herrera MF, M.D. Pressure-induced rhabdomyolysis after bariatric surgery. Obesity Surg. 2003;13(2):297-301. http://search.proquest.com/docview/821093761?accountid=6741. doi: http://dx.doi.org/10.1381/096089203764467252.</ref><br><br>  =
 
<br>Bodyweight &gt;30% of ideal<br>Surgical Time &gt; 4 hours<br>Intravascular Volume Depletion (Hematocrit &gt;50, Na &gt;150 mEq/l, orthostatism, pulmonary wedge pressure &lt;5 mm Hg, FENa &lt;1%)<br>Preexistent azotemia<br>Diabetes Mellitus<br>Systemic Arterial Hypertension<br>CPK peak &gt;6,000 IU/l<br>Sepsis<br>Hyperkalemia or Hypophosphatemia<br>Hypoalbminemia<br><br>
 
<br>
 
<br>
 
= Characteristics/Clinical Presentation  =
 
The signs and symptoms of rhabdomyolyis vary from person to person. The three most common signs and symptoms are muscle pain, weakness, and dark urine.<ref name="A" /><ref name="E" /> Muscle pain as well as weakness and tenderness may be general or specific to muscle groups. The calves and low back are the most general muscle groups that are affected.<ref name="A" /> According to the author Efstratiadis, back pain and limb pain are the most frequent sites in patients with rhabdomyolysis.<ref name="E" /> However, over 50% of the patients with rhabdomyolysis may not complain of muscle pain or weakness.<ref name="A" /> The initial sign of rhabdomyolysis is discolored urine which can range from pink to dark black.<ref name="A" /><ref name="E" /> Other signs and symptoms include, local edema, cramps, hypotension, malaise, fever, tachycardia, nausea and vomiting.<ref name="A" /><ref name="E" /> Often during the early stages of rhabdomyolysis the following conditions may also be present: hyperkalemia, hypocalcemia, elevated liver enzymes, cardiac dysrrhythmias and cardiac arrest.<ref name="A" /> Some late complications include acute renal failure and disseminated intravascular coagulation.<ref name="A" /><br>
 
= Complications of Rhabdomyolysis&nbsp;<ref name="rev" />  =
 
Hypovolemia
 
Compartment syndrome
 
Arrhythmias and cardiac arrest
 
Disseminated intravascular coagulation


Hepatic dysfunction
Calcium accumulation in the muscles occurs in the early stages of rhabdomyolysis. &nbsp;Massive calcification of necrotic muscles can occur which can lead to [[hypercalcemia]].<ref name="b" /> &nbsp;If hyperkalemia is present hypercalcemia can lead to cardiac arrhythmias, muscular contraction, or [[Epilepsy|seizure]]<nowiki/>s.<ref name="V" />


Acidosis
==Etiology==
The etiology for rhabdomyolysis can be classified into two broad categories. Traumatic or physical causes and nontraumatic or nonphysical causes.


Acute renal failure
The most common causes of rhabdomyolysis are trauma, immobilization, sepsis, and cardiovascular surgeries<ref name=":2" />.  Causes of rhabdomyolysis include:
* trauma or crush injuries, eg car accident
* taking [[Substance Use Disorder|illegal drugs]] eg cocaine, amphetamines or heroin
* extreme muscle exertion, eg running marathons or improper resistance training
* a side effect of some medicines, eg cholesterol-lowering drugs ([[statins]]) or amphetamines used for [[Attention Deficit Disorders|ADHD]], although the risk is very low
* prolonged muscle pressure eg when someone is lying unconscious on a hard surface
* [[hyperthermia]] or heat stroke
* [[dehydration]]
* high [[fever]]
* an [[Infectious Disease|infection]]
* being bitten or stung by wasps, hornets or snakes
* having a seizure
* drinking too much [[Alcoholism|alcohol]]
* being born with some [[Genetic Disorders|genetic condition]]<nowiki/>s or [[Muscular Dystrophy|muscular dystrophies]]


Death
You are at greater risk of rhabdomyolysis if you are an [[Older People - An Introduction|older adult]], have [[diabetes]], take part in extreme sports or use a lot of drugs or alcohol.<ref name=":0" />


= Diagnostic Tests/Lab Tests/Lab Values  =
==Characteristics/Clinical Presentation ==


Blood samples are taken from the patient to look at various serum values, one of the most important serum indicators of myocyte injury is creatinine kinase.<ref name="E" />  
The signs and symptoms of rhabdomyolyis vary from person to person. The three most common signs and symptoms are muscle pain, weakness, and dark urine.<ref name="A" /><ref name="E" />  


'''Creatinine Kinase[[Image:Table 2.1.png|frame|right|Courtesy Of: Efstratiadis G, Voulgaridou A, Nikiforou D, et al. Rhabdomyolysis updated. Hippokratia 2007; 11(3): 129-13]]'''
Muscle pain as well as weakness and tenderness may be general or specific to muscle groups. The [[Gastrocnemius|calves]] and low back are the most general muscle groups that are affected.<ref name="A" /> According to the author Efstratiadis, [[Low Back Pain|back pain]] and limb pain are the most frequent sites in patients with rhabdomyolysis.<ref name="E" /> However, over 50% of the patients with rhabdomyolysis may not complain of muscle pain or weakness.<ref name="A" />


"Under normal conditions, CK levels are 45-260 U/L. After rhabdomyolysis, the levels of CK can be raised to 10.000-200.000 U/L or even 3.000.000.000 U/L.<span style="">&nbsp; </span>No other condition except rhabdomyolysis can cause such extreme CK elevation.”<ref name="E" /><span style="">&nbsp;&nbsp;</span>  
* The initial sign of rhabdomyolysis is discolored [[urine]] which can range from pink to dark black.<ref name="A" /><ref name="E" />
* Other signs and symptoms include, local edema, cramps, [[hypotension]], malaise, fever, tachycardia, nausea and vomiting.<ref name="A" /><ref name="E" />  
* Often during the early stages of rhabdomyolysis the following conditions may also be present: [[hyperkalemia]], [[hypocalcemia]], elevated [[Liver Function Tests|liver]] enzymes, cardiac dysrrhythmias and [[Heart Failure|cardiac arrest]].<ref name="A" />  
* Some late complications include acute renal failure and disseminated intravascular coagulation.<ref name="A" />


Creatine Kinase has several forms that include the muscles, heart, brain and kidneys, as well as mitochndria so it is important to look at all values.
= Diagnosis =


'''Uric Acid'''
Blood tests for creatine kinase, a product of muscle breakdown, and urine tests for myoglobin can help diagnose rhabdomyolysis (although in half of people with the condition, the myoglobin test may come up negative). Other tests may rule out other problems, confirm the cause of rhabdomyolysis, or check for complications.


Uric Acid is important to check due to the fact that rhabdomyolysis breaks down skeletal muscle creating more creatinine, which then becomes creatinine which can then lead to acute renal failure, therefore causing the levels of uric acid to rise.  
* Common complications of rhabdomyolysis include very high levels of potassium in the blood, which can lead to an irregular heartbeat or [[Cardiac Arrest|cardiac arrest]] and kidney damage (which occurs in up to half of patients).
* About one in four also develop problems with their [[Liver Disease|liver]].
* [[Compartment Syndrome|Compartment syndrome]] may also occur after fluid resuscitation. This serious compression of nerves, blood vessels, and muscles can cause tissue damage and problems with blood flow<ref name=":1">WebMd [https://www.webmd.com/a-to-z-guides/rhabdomyolysis-symptoms-causes-treatments Rhabdomyolysis] Available: https://www.webmd.com/a-to-z-guides/rhabdomyolysis-symptoms-causes-treatments (accessed 17.9.2021)</ref>.
==Treatment==
Early diagnosis and treatment of rhabdomyolysis and its causes are keys to a successful outcome. You can expect full recovery with prompt treatment. Doctors can even reverse kidney damage. However, if compartment syndrome is not treated early enough, it may cause lasting damage.


'''Urinalysis[[Image:Table 3.png|frame|Courtesy Of: Efstratiadis G, Voulgaridou A, Nikiforou D, et al. Rhabdomyolysis updated. Hippokratia 2007; 11(3): 129-137]]<br>'''
Clients with rhabdomyolysis, you will be admitted to the hospital. Treatment with intravenous (IV) fluids helps maintain urine production and prevent kidney failure. Rarely, dialysis treatment may be needed to help kidneys filter waste products while they are recovering. Management of electrolyte abnormalities (potassium, calcium and phosphorus) helps protect the heart and other organs. Client may also need a surgical procedure (fasciotomy) to relieve tension or pressure and loss of circulation if compartment syndrome threatens muscle death or nerve damage. In some cases, client may need to be in the intensive care unit (ICU) to allow close monitoring.


<span style="font-family: helvetica;">Urine analysis can be very helpful in diagnosing rhabdomyolysis.<span style="">&nbsp; </span>Urinalysis will be able to detect changes in the body’s waste, such as increases in uric acid, albumin, as well as myoglobin.<ref name="E" /><span style="">&nbsp;&nbsp;</span>Often patients that are positive for rhabdomyolysis have brown tinted urine.<span style="">&nbsp; </span>Table 3 has a description of common findings in urinalysis.</span><br>  
* Most causes of rhabdomyolysis are reversible.
* If rhabdomyolysis is related to a medical condition, such as diabetes or a thyroid disorder, appropriate treatment for the medical condition will be needed. And if rhabdomyolysis is related to a medication or drug, its use will need to be stopped or replaced with an alternative.<ref name=":1" />


<u>'''Causes of Reddish-Brown Discoloration of the Urine<ref name="V" />'''</u>  
*Hyperkalemia may be fatal and should be corrected vigorously
*Hypocalcemia should be corrected only if it causes symptoms
*[[Compartment Syndrome|Compartment syndrome]] requires immediate orthopaedic consultation for fasciotomy<ref name="rev">Khan F. Rhabdomyolysis: a review of the literature. The Netherlands Journal Of Medicine [serial online]. October 2009;67(9):272-283. Available from: MEDLINE, Ipswich, MA. Accessed March 23, 2014.</ref>


<u>Myoglobinuria</u>
==Physiotherapy Management==
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp;Rhabdomyolysis
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Traumatic
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Non-Traumatic&nbsp;
 
<u>Hemoglobinuria</u>
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp;Hemolysis
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Mechanical Damage
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Immunologic Damage
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Structural Fragility of Erythrocytes
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Microangiopathy
 
<u>Hematuria[[Image:Urine color.png|frame|right|Courtesy of: Vanholder R, Mehmet S, Erek E, Lameire N. Rhabdomyolysis. Journal of the American Society of Nephrology 2000; 1553-1561.]]</u>
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp;Renal Causes
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp;Post Renal Causes
 
<u>External Factors</u>
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp;Red Beets
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp;Drugs
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Vitamin B12
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Rifampicin
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Phenolphthalein
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Phenytoin
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp;Metabolites
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Bilirubin
 
&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Porphyrin
 
= Systemic Involvement  =
 
Systemic involvement for rhabdomyolysis includes the muscle groups that have been directly involved such as during a crush injury or overuse. &nbsp;Once the breakdown of muscle occurs the by-product will then filter into the renal system, which if gone untreated can lead to renal failure.
 
= Medical Management (current best evidence)  =
 
The best medical management for rhabdomyolysis is stabilizing the patient and aggressive fluid replacement with saline to preserve renal function.<ref name="A" /><ref name="E" /><span style="">&nbsp;&nbsp;</span>It is also suggested that fluids be given to victims before extraction.<span style="">&nbsp; </span>The increase in fluids helps to expand the intravascular volume, thereby inducing diuresis and clearance of toxins.<ref name="E" /><span style="">&nbsp;&nbsp;</span>It Is recommended that patients should be given 10 or more liters of fluid per day, so that they maintain a urine output of 150-300 ml/per hour.<ref name="E" /><span style="">&nbsp;&nbsp;</span>Sometimes mannitol and bicarbonate are given during the initial resuscitation.<span style="">&nbsp; </span>It is believed that mannitol acts as a free-radical scavenger minimizing cell injury.<span style="">&nbsp; </span>Mannitol is also a renal vasodilator to prevent renal failure.<span style="">&nbsp; </span>Bicarbonate is given to help correct the effects of metabolic acidosis and enhance myoglobin.<ref name="E" /><span style="">&nbsp;&nbsp;</span>Along with the patient’s vital signs and urine output, the patient’s electrolytes should be closely monitored.
 
<br>
 
=== <u>Prehospital Care<ref name="rev" /></u>  ===
 
*ABC&nbsp;assessment<br>
*Intravenous access<br>
*Consider the importance of early fluid administration in the field<br>
*NS infusion at a rate of 1.5 liters/ hour, to maintain a urine output of 200-300 ml/hour<br>
*Avoid empirical administration of potassium and lactate-containing fluids<br>
 
<br>
 
=== <u>In hospital Care</u><ref name="rev" /><br>  ===
 
*Aggressive intravenous rehydration<br>
*A careful history and physical examination<br>
*Closely monitor serum electrolyte and CK<br>
*Monitor fluid intake and urinary output (urinary catheter insertion).<br>
*Check limbs for compartment syndromes<br>
*Hemodynamic monitoring (central venous pressure measurements).<br>
*Administer mannitol and bicarbonate (for patients with crush injury): a 20% mannitol infusion at a dose of 0.5 g/kg an infusion at 0.1 g/kg/h. Adjustments are made to maintain urine output &gt;200ml/h. Sodium bicarbonate, one ampoule (44 mEq) added to 1 l of 1/2 NS or two to three ampoules (88 to 132 mEq) in D5W to run at a rate of 100ml/hour, has been recommended to maintain a urinary pH of ≤6.5 to prevent the development of ARF<br>
*Intensive care monitoring (for critically ill patients)
 
=== <u>Treatment of any reversible cause of muscle damage</u><ref name="rev" /><br>  ===
 
*Correct electrolyte and metabolic abnormalities<br>
*Treat hyperthermia and hypothermia
*Eliminate and detoxify drugs and toxins
 
=== <u>Management and prevention of complications</u><ref name="rev" />  ===
 
*Hyperkalemia may be fatal and should be corrected vigorously
*Hypocalcemia should be corrected only if it causes symptoms
*Hypophosphatemia and hyperphosphatemia with oral phosphate binders when serum levels exceed 7 mg/dl
*Compartment syndrome requires immediate orthopaedic consultation for fasciotomy
*DIC usually usually resolves spontaneously after several days if the underlying cause is corrected, but if haemorrhagic compliations occur, therapy with platelets, vitamin k, and fresh frozen plasma may be necessary
*Hyperuricaemia and hyperphophatemia are rarely of clinical significance and rarely require treatment
*Consider dailysis as a lifesaving procedure for patients with rising or elevated potasum level, persistent acidosis, or oliguric renal failure with fluid overload
*Consider continuing dialysis support until patients' kidney function has recovered
 
<br> <br>
 
=== <u><span style="font-family: helvetica;">Dialysis</span></u>  ===
 
Unfortunately, patients that have rhabdomyolysis are more likely to develop acute renal failure.<span style="">&nbsp; </span>A common treatment for acute renal failure is dialysis to correct fluid, electrolytes, and acid-base abnormalities.<span style="">&nbsp; </span>This is a slow process to correct the fluid overload and as well as removal of potassium and urea.<ref name="A" />
 
=== <u>'''Medications'''</u>  ===
 
A patient wil rhabdomyolysis will not take medications on a regular basis, they will only take them in the emergency medical treatment. &nbsp;However, patients are encouraged to drink lots of water throughout treatment.
 
= Physical Therapy Management (current best evidence) =


It is important to keep in mind the cause of rhabdomyolysis. It is important to not overexert the patient to prevent them from creating more muscle breakdown. &nbsp;The most important thing is for the patient to retain range of motion as well as to properly hydrate.  
It is important to keep in mind the cause of rhabdomyolysis. It is important to not overexert the patient to prevent them from creating more muscle breakdown. &nbsp;The most important thing is for the patient to retain range of motion as well as to properly hydrate.  


The physical therapist treating a patient with rhabdomyolysis must make sure that the patient is not having any urinary problems which includes urine color.<ref name="ER">Brown T. Exertional Rhabdomyolysis: Early Recognition is Key. The Physician and Sports Medicine 2004; 32: 1-5</ref>&nbsp;Some interventions would include range of motion exercises both active and passive, aerobic training, and gradual resistance training.<ref name="ER" />  
The physical therapist treating a patient with rhabdomyolysis must make sure that the patient is not having any urinary problems which includes urine color.<ref name="ER">Brown T. Exertional Rhabdomyolysis: Early Recognition is Key. The Physician and Sports Medicine 2004; 32: 1-5</ref> Some interventions would include range of motion exercises (both active and passive), [[Aerobic Exercise|aerobic]] training, and gradual resistance training.<ref name="ER" />


<br>  
In a recent study on rehabilitation for Rhabdomyolysis associated with breast cancer treatment, it was reported that physical activity such as strengthening and aerobic exercises were safe and beneficial to minimise immobility <ref>Burns G, Wilson CM. Rehabilitation for Rhabdomyolysis Associated With Breast Cancer Treatment. Cureus. 2020 Jun 15;12(6).</ref>. Exercise is crucial for reducing cancer-related fatigue, enhancing quality of life, and preventing unnecessarily long treatment wait times. It is preferable to take a holistic approach when treating a patient who is under intense physical and mental strain using Cognitive Behavioural Therapy (CBT). The settings for effective physical rehabilitation in aiding a person's improvement of independence, safety, and confidence were supplied by the coordination of transitions from acute care to in-patient rehabilitation in conjunction with holistic approach.


=== <u>Exertional Rhabdomyolysis and Return to Sport</u>  ===
===Exertional Rhabdomyolysis and Return to Sport===


<br>A client’s fitness level is extremely important when considering the development of a workout program. Exertional rhabdomyolysis may occur when a client is not accustomed to the mode or intensity of the exercise prescribed. Fitness professionals must understand the importance of initial fitness level and progressional overload so that the exercise stress challenges the client appropriately. Fitness specialists should also consider the risks when providing eccentric training in a hot environment or if the client has any genetic risk factors for rhabdomyolysis.  
<br>A client’s fitness level is extremely important when considering the development of a workout program. Exertional rhabdomyolysis may occur when a client is not accustomed to the mode or intensity of the exercise prescribed. Fitness professionals must understand the importance of initial fitness level and progressional overload so that the exercise stress challenges the client appropriately. Fitness specialists should also consider the risks when providing eccentric training in a hot environment or if the client has any genetic risk factors for rhabdomyolysis.  


=== <br>'''<u>Physical Therapy Management Return to Sport</u>''' <ref name="ath">Tietze DC, Borchers J. Exertional Rhabdomyolysis in the Athlete: A Clinical Review. Sports Health: A Multidisciplinary Approach. 2014;:1941738114523544.</ref><br>  ===
=== Physical Therapy Management Return to Sport===


There is currently no evidence based guidelines for return to play after an episode of exertional rhabdomyolysis. However, a conservative return to sport protocol has been described by Consortium for Health and Military Performance (CHAMP) and is listed below.  
There is currently no evidence based guidelines for return to play after an episode of exertional rhabdomyolysis. However, a conservative return to sport protocol has been described by Consortium for Health and Military Performance (CHAMP) and is listed below.<ref name="ath">Tietze DC, Borchers J. Exertional Rhabdomyolysis in the Athlete: A Clinical Review. Sports Health: A Multidisciplinary Approach. 2014;:1941738114523544.</ref>


<br>  
[[Image:Returntosport.png|708x429px]] <ref name="ath" /><br>Image Courtesy of David C. Tietze, M.D.


[[Image:Returntosport.png|708x429px]] <ref name="ath" /><br>Image Courtesy of David C. Tietze, M.D.<br>
Schleich et al, outlined a phased reintegration program for safe and effective return to play post exertional rhabdomyolysis (table 1 below). Following phase IV, athletes in the study continued with agility work, speed development, and resistance training under the supervision of strength and conditioning staff. Each athletes return-to-play time will vary depending on severity of rhabdomyolysis, previous fitness level, training experience and maturation.  


<br>
<u>'''Table 1. Overview of Phased Return&nbsp;<ref>Schleich, K., Slayman, T., West, D. and Smoot, K. (2016). Return to Play After Exertional Rhabdomyolysis. Journal of Athletic Training, 51(5), pp.406-409.</ref>'''</u><br>''Phase 1:&nbsp;Activities &nbsp;''<br>Return to activities of daily living for 2 wk<br>Regular monitoring by athletic training staff<br>Screening for symptoms consistent with exertional rhabdomyolysis, sleep patterns, hydration, urine color, and class attendance<br>Monitoring of creatinine kinase and serum creatinine by primary care physician<br>Phase 2: Activities <br>Daily monitoring of hydration status, muscle soreness, and swelling<br>Initiation of physical activity: foam rolling, dynamic warm-up, aquatic jogging, and stretching<br>Phase 3: Activities <br>Daily monitoring of hydration status, muscle soreness, and swelling<br>Progression of physical activity: body-weight resistance movements, resistance training with elastic band, core training, stationary bicycling, and stretching<br>Phase 4: Activities<br>Daily monitoring of hydration status, muscle soreness, and swelling<br>Initiation of resistance training at 20%–25% of estimated 1-repetition maximum, agility exercises, and running <br><u>'''Risk stratification for recurrent rhabdomyolysis'''</u>&nbsp;<ref>O'Connor, F., Brennan, F., Campbell, W., Heled, Y. and Deuster, P. (2008). Return to Physical Activity After Exertional Rhabdomyolysis. Current Sports Medicine Reports, 7(6), pp.328-331.</ref><br>According to O’Connor et al., an athlete who experiences clinically relevant exertional rhabdomyolysis (ER) should first be risk-stratified as either low or high risk for a recurrence. <br>To be considered "suspicious for high risk,' at least one of the following conditions must exist or be present:<br>a. Delayed recovery (more than 1 wk) when activities have been restricted<br>b. Persistent elevation of CK (greater than five times the upper limit of the normal lab range) despite rest for at least 2 wk<br>c. ER complicated by acute renal injury of any degree<br>d. Personal or family history of ER<br>e. Personal or family history of recurrent muscle cramps or severe muscle pain that interferes with activities of daily living or sports performance<br>f. Personal or family history of malignant hyperthermia, or family history of unexplained complications or death following general anesthesia<br>g. Personal or family history of sickle cell disease or trait<br>h. Muscle injury after low to moderate work or activity<br>i. Personal history of significant heat injury (heat stroke)<br>j. Serum CK peak ≥ 100,000 U·L−1.<br>To be considered a "low risk" athlete, none of the high-risk conditions should exist, and at least one of the following conditions must exist or be present:<br>a. Rapid clinical recovery and CK normalization after exercise restrictions<br>b. Sufficiently fit or well trained athlete with a history of very intense training/exercise bout<br>c. No personal or family history of rhabdomyolysis or previous reporting of debilitating exercise-induced muscle pain, cramps, or heat injury<br>d. Existence of other group or team-related cases of ER during the same exercise sessions<br>e. Suspected or documented concomitant viral illness or infectious disease<br>f. Taking a drug or dietary supplement that could contribute to the development of ER<br>Complete history and physical examination should be completed and referral to experts for consideration of myopathic disorders before return to sport for any individual at high risk.<br><u>'''Prevention of recurrent episodes in pre-disposed individuals <ref>Hannah-Shmouni F, McLeod K, Sirrs S. Recurrent exercise-induced rhabdomyolysis. CMAJ : Canadian Medical Association Journal. 2012;184(4):426-430. doi:10.1503/cmaj.110518.</ref>'''</u><br>Regardless of cause:<br>• Avoid triggers<br>• Hydrate<br>• Warm-up before exercise<br>Fatty acid beta-oxidation:<br>• Low fat diet<br>• Replacement of essential fatty acids with walnut or soy oils<br>Vitamin D deficiency:<br>• Monitoring and normalization of vitamin D levels


= Differential Diagnosis  =
<u>'''Brief video regarding physical therapy management<ref>Schleich, K., Slayman, T., West, D. and Smoot, K. (2016). Return to Play After Exertional Rhabdomyolysis. Journal of Athletic Training, 51(5), pp.406-409.</ref><ref>O'Connor, F., Brennan, F., Campbell, W., Heled, Y. and Deuster, P. (2008). Return to Physical Activity After Exertional Rhabdomyolysis. Current Sports Medicine Reports, 7(6), pp.328-331.</ref>'''</u>


=== Most Common Differential Diagnoses<u>'''<ref name="M">Muscal E. Rhabdomyolysis: Differential Diagnoses and Workup. eMedicine 2009.</ref>'''</u>  ===
https://www.youtube.com/watch?v=NDdoiNNaMKI<br>
 
== Differential Diagnosis ==
*Burns, Electrical  
Most Common Differential Diagnoses<ref name="M">Muscal E. Rhabdomyolysis: Differential Diagnoses and Workup. eMedicine 2009.</ref>
*Carnitine Deficiency  
*Burns, Electrical
*Child Abuse and Neglect, physical abuse  
*Carnitine Deficiency
*Dermatomyositis  
*Child Abuse and Neglect, physical abuse
*Multisystem Organ Failure of Sepsis  
*[[Dermatomyositis]]
*Myoglobinuria<ref name="V" />  
*Multisystem Organ Failure of Sepsis
*Neuroleptic Malignant Syndrome  
*Myoglobinuria<ref name="V" />
*Sepsis  
*Neuroleptic Malignant Syndrome
*Systemic Inflammatory Response Syndrome  
*[[Sepsis]]
*Systemic Lupus Erythmatosus  
*[[Multisystem Inflammatory Syndrome in Children (MIS-C)|Systemic Inflammatory Response Syndrome]]
*Thromboembolism  
*[[Systemic Lupus Erythematosus|Systemic Lupus Erythmatosus]]
*Toxic Shock Syndrome  
*Thromboembolism
*Toxic Shock Syndrome
*Toxicity, Ethanol
*Toxicity, Ethanol


=== Other Problems to Consider<u>'''<ref name="M" />'''</u>  ===
== References ==
 
<references />
Traumatic injuries
, Viral infections, 
Myalgias from other etiologies, 
Bacterial infections, 
Pyomyositis, 
Heatstroke
, Cold exposure, 
Snakebite, 
Malignant hyperthermia, 
Muscle phosphorylase deficiency, 
Phosphofructokinase deficiency, 
Carnitine palmityl transferase deficiency, 
Phosphoglycerate mutase deficiency, 
Other inborn errors of metabolism, 
Hyperosmotic conditions, 
Guillain-Barré syndrome, 
Inflammatory myositis.
 
<br>
 
== [[Rhabdomyolysis Case Study|Rhabdomyolysis Case Study]]  ==
 
= Case Report (Diagnosis and Treatment of Acute Exertional Rhabdomyolysis)<ref name="JOSPT">Baxter R, Moore J. Diagnosis and Treatment of Acute Exertional Rhabdomyolysis. Journal of Orthopaedic and Sports Physical Therapy 2003; 33(3): 104-108</ref>  =
 
== <span class="mw-headline">Subjective Findings</span>  ==
 
Patient &nbsp;was a walk in to the US Military Academy Cadet Physical Therapy Clinic complaining of bilateral shoulder pain and weakness. &nbsp;The patient reported performing hundreds of push up of varying types 36 hours earlier. &nbsp;The patient reported being in pain and that he had noticed dark colored urine 24 hours after his push up session.
 
== <span class="mw-headline">Objective Findings</span>  ==
 
<u>'''Range of Motion'''</u>
 
Bilateral shoulder AROM restricted below 90 degrees elevation with abnormal scapulohumeral rhythm (excessive scapular elevation bilaterally)
 
PROM was within normal limits but caused pain in the pectoralis and triceps near end range shoulder elevation
 
Left elbow AROM and PROM were restricted to 90 degrees flexion due to pain and induration in the left triceps.
 
<u>'''Strength[[Image:Before.png|thumb|right|300x200px|Patient's ROM before intervention]]'''</u>
 
Shoulder ER 3+/5
 
All other muscle strength assessment was deferred due to the severity and irritability of the patient's symptoms
 
<u>'''Special Tests'''</u>
 
Shoulder impingement tests were negative (Hawkins-Kennedy and Neer)
 
Exquisite tenderness to palpation bilaterally in the pectoralis, triceps, and infraspinatus muscle, as well as in the bicipital groove
 
'''<u>Laboratory Tests</u>'''
 
'''<u></u>'''Serum CK, completed blood count, and urinalysis were ordered
 
Serum CK was listed as 9,600 U/L (normal range 55-170 U/L)
 
Urinalysis noted that the urine was brown<br>
 
== <span class="mw-headline">Management</span>  ==
 
Patient was diagnosed with Acute Exertional Rhabdomyolysis and was admitted to the hospital. &nbsp;He was given aggressive fluid replacement. While in inpatient he performed AAROM in shoulders and in elbows. &nbsp;Patient was discharged after 4 days and then returned to the outpatient clinic.
 
<u>'''Outpatient'''</u>
 
'''Randall et al's Rehabilitation program for patients with with acute exertional rhabdomyolysis secondary to intense push-up training'''
 
'''Phase 1'''
 
&nbsp;&nbsp; &nbsp; Active and gentle passive ROM of the shoulder and elbow within limits of pain
 
'''Phase 2'''
 
&nbsp;&nbsp; &nbsp; Initiated once active ROM is normal. &nbsp;Upper body ergometer at low intensity for 5 minutes progressing daily until this workload can be maintained for 15 minutes.
 
'''Phase 3'''
 
&nbsp;&nbsp; &nbsp; Initiated once the patient can maintain 15 minutes, on the upper body ergometer without discomfort, change in technique, or muscle soreness 24 hours post exercise. &nbsp;Progress to isotonic weight training with light weights for specific muscle weakness (ex. elbow extension for triceps), modified pushups, and bench press. &nbsp;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'''
 
&nbsp;&nbsp; &nbsp; Initiated once patient progresses to pushups without modification. &nbsp;Patient is allowed to resume normal exercise routine with the restriction of only performing 1 set of pushups in any 24 hour period. This restriction in maintained until the patient is able to perform at their preinjury number of pushups without sequelae such as muscle soreness or loss of normal ROM.<br>
 
== <span class="mw-headline">Outcome</span>  ==
 
<u>'''First Outpatient Visit'''</u>
 
<u>Shoulder AROM:&nbsp;[[Image:After.png|thumb|right|300x400px|Picture of patient's ROM after interventions]]</u>
 
&nbsp;&nbsp; &nbsp;Flexion 155 degrees
 
&nbsp;&nbsp; &nbsp;Abduction 170 degrees
 
&nbsp;&nbsp; &nbsp;External Rotation 55 degrees
 
&nbsp;&nbsp; &nbsp;Internal Rotation 65 degrees
 
<u>Strength</u>
 
&nbsp;&nbsp; 5/5 for shoulder shrug, internal rotation, and elbow flexion
 
&nbsp;&nbsp; 4/5 or 4-/5 for shoulder abduction, flexion, external rotation, supraspinatus and triceps
 
CK level 5,721 U/L
 
<u>'''Eight Day Post Diagnosis'''</u>
 
Full AROM
 
Began Radall et al.Protocol
 
<u>'''Thirty-Seven Days Post Diagnosis'''</u> - serum CK levels normal
 
<u>'''Seventy- One Days Post Diagnosis'''</u> - patient's full strength was back and was able to perform 60 pushups in one continuous bout<br>
 
<br>
 
<br>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox"><rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1fQ8NaQxbRgBecjmvSoM6sMFne7N5Tz2-yoPXsWr8-2fiCDkxn|charset=UTF-8|short|max=10</rss></div>
== References ==
 
see [[Adding References|adding references tutorial]].
 
<references />  


[[Category:Bellarmine_Student_Project]] [[Category:Videos|Videos]]
[[Category:Bellarmine_Student_Project]]
[[Category:Older People/Geriatrics]]
[[Category:Falls]]
[[Category:Musculoskeletal/Orthopaedics]]

Latest revision as of 02:47, 7 February 2024

Original Editors - Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Emily Kordik, Michael Beavin, George Tate, Elaine Lonnemann, Admin, Lucinda hampton, Scott Buxton, Kim Jackson, Jason Copelin, WikiSysop, 127.0.0.1, Candace Goh and Lauren Lopez  

Definition/Description[edit | edit source]

RhabdoUrine.jpeg

Rhabdomyolysis is a serious condition caused by muscle injury. Rhabdomyolysis is serious and can be life-threatening[1]. 

  • The etiology of rhabdomyolysis can be classified as: nontraumatic eg infections ; or traumatic, traumatic rhabdomyolysis are crush syndrome from accidents, earthquakes, and other natural and manufactured disasters[2].
  • When muscle tissue gets seriously injured, it breaks down and dies, releasing its contents (including myoglobin) into the bloodstream. Myoglobin is toxic to the kidneys, and can lead to kidney complications, such as kidney failure, and changes in balance of electrolytes in the blood, which can lead to serious problems with the heart and other organs[1].

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

Epidemiology[edit | edit source]

Approximately 25,000 cases of rhabdomyolysis are reported each year in the USA.

  • The prevalence of acute kidney injury in rhabdomyolysis is about 5 to 30%[2]
  • Eighty-five percent of victims of traumatic injuries develop rhabdomyolysis.[3]   
  • It is also suggested that victims of severe injury that develop rhabdomyolysis and later acute renal failure have a mortality of 20%.[3]
  • Rhabdomyolysis can occur at any age, but the majority of cases are seen in adults.
  • Males, African-American race, obesity, age more than 60 are factors that demonstrate a higher incidence of rhabdomyolysis.
  • The most common cause for rhabdomyolysis in children is infection(30%). [2]

Pathophysiology[edit | edit source]

Rhabdomyolysis occurs due to injury eg mechanical, chemical, toxins, poisons, burns. These injuries have a detrimental effect to the cell membranes throughout the body. When a cell membrane is damaged the breakdown releases organic and inorganic intracellular components eg potassium, myoglobin, lactic acid, purines, and phosphate which enter the circulation.[4]  

After the restoration of blood flow after the injury these components become toxic to the body and in most cases are life threatening, making rhabdomyolysis a medical emergency.[5] Myoglobin levels rise within hours of muscle damage, but can return to normal in 1-6 hours if continuous muscle injury is not present.[6]

Myoglobin is usually filtered through glomeruli (of the kidneys) and reabsorbed in the proximal tubules by endocytosis, however when rhabdomyolysis occurs there is an excess of myoglobin, which overloads the proximal tubule cells ability to convert iron to ferritin, which then results in intracellular ferrihemate accumulation.[6] Since iron can donate and except electrons as well as having the ability to generate free radicals the urine’s pH can lead to metabolic acidosis.  This process puts oxidative stress and injury to the renal cells, which if untreated can lead to renal cell failure.[5]

When there is an excess of myoglobin the tubules are unable to reabsorb it.[5][4] Systemic vasoconstriction sets in which results in water reabsorption in renal tubules, which then increases myoglobin concentration in urine.  This in turn causes formation of casts that obstruct renal tubules. Another contributing factor of cast formation is apoptosis that occurs in epithelial cells.[6]  This obstruction causes formation of free radicals from iron, which can lead to renal failure.[5]

Potassium is another byproduct of muscle lysis.  With too much potassium in the circulation hyperkalemia can occur, which is life threatening, due to its cardiotoxicty effects.[5] Cardiac arrhythmias can occur due to increased levels of potassium in the blood. In some cases, early death occurs due to ventricular fibrillation.[7]

Calcium accumulation in the muscles occurs in the early stages of rhabdomyolysis.  Massive calcification of necrotic muscles can occur which can lead to hypercalcemia.[6]  If hyperkalemia is present hypercalcemia can lead to cardiac arrhythmias, muscular contraction, or seizures.[4]

Etiology[edit | edit source]

The etiology for rhabdomyolysis can be classified into two broad categories. Traumatic or physical causes and nontraumatic or nonphysical causes.

The most common causes of rhabdomyolysis are trauma, immobilization, sepsis, and cardiovascular surgeries[2]. Causes of rhabdomyolysis include:

  • trauma or crush injuries, eg car accident
  • taking illegal drugs eg cocaine, amphetamines or heroin
  • extreme muscle exertion, eg running marathons or improper resistance training
  • a side effect of some medicines, eg cholesterol-lowering drugs (statins) or amphetamines used for ADHD, although the risk is very low
  • prolonged muscle pressure eg when someone is lying unconscious on a hard surface
  • hyperthermia or heat stroke
  • dehydration
  • high fever
  • an infection
  • being bitten or stung by wasps, hornets or snakes
  • having a seizure
  • drinking too much alcohol
  • being born with some genetic conditions or muscular dystrophies

You are at greater risk of rhabdomyolysis if you are an older adult, have diabetes, take part in extreme sports or use a lot of drugs or alcohol.[1]

Characteristics/Clinical Presentation[edit | edit source]

The signs and symptoms of rhabdomyolyis vary from person to person. The three most common signs and symptoms are muscle pain, weakness, and dark urine.[3][5]

Muscle pain as well as weakness and tenderness may be general or specific to muscle groups. The calves and low back are the most general muscle groups that are affected.[3] According to the author Efstratiadis, back pain and limb pain are the most frequent sites in patients with rhabdomyolysis.[5] However, over 50% of the patients with rhabdomyolysis may not complain of muscle pain or weakness.[3]

  • The initial sign of rhabdomyolysis is discolored urine which can range from pink to dark black.[3][5]
  • Other signs and symptoms include, local edema, cramps, hypotension, malaise, fever, tachycardia, nausea and vomiting.[3][5]
  • Often during the early stages of rhabdomyolysis the following conditions may also be present: hyperkalemia, hypocalcemia, elevated liver enzymes, cardiac dysrrhythmias and cardiac arrest.[3]
  • Some late complications include acute renal failure and disseminated intravascular coagulation.[3]

Diagnosis[edit | edit source]

Blood tests for creatine kinase, a product of muscle breakdown, and urine tests for myoglobin can help diagnose rhabdomyolysis (although in half of people with the condition, the myoglobin test may come up negative). Other tests may rule out other problems, confirm the cause of rhabdomyolysis, or check for complications.

  • Common complications of rhabdomyolysis include very high levels of potassium in the blood, which can lead to an irregular heartbeat or cardiac arrest and kidney damage (which occurs in up to half of patients).
  • About one in four also develop problems with their liver.
  • Compartment syndrome may also occur after fluid resuscitation. This serious compression of nerves, blood vessels, and muscles can cause tissue damage and problems with blood flow[8].

Treatment[edit | edit source]

Early diagnosis and treatment of rhabdomyolysis and its causes are keys to a successful outcome. You can expect full recovery with prompt treatment. Doctors can even reverse kidney damage. However, if compartment syndrome is not treated early enough, it may cause lasting damage.

Clients with rhabdomyolysis, you will be admitted to the hospital. Treatment with intravenous (IV) fluids helps maintain urine production and prevent kidney failure. Rarely, dialysis treatment may be needed to help kidneys filter waste products while they are recovering. Management of electrolyte abnormalities (potassium, calcium and phosphorus) helps protect the heart and other organs. Client may also need a surgical procedure (fasciotomy) to relieve tension or pressure and loss of circulation if compartment syndrome threatens muscle death or nerve damage. In some cases, client may need to be in the intensive care unit (ICU) to allow close monitoring.

  • Most causes of rhabdomyolysis are reversible.
  • If rhabdomyolysis is related to a medical condition, such as diabetes or a thyroid disorder, appropriate treatment for the medical condition will be needed. And if rhabdomyolysis is related to a medication or drug, its use will need to be stopped or replaced with an alternative.[8]
  • Hyperkalemia may be fatal and should be corrected vigorously
  • Hypocalcemia should be corrected only if it causes symptoms
  • Compartment syndrome requires immediate orthopaedic consultation for fasciotomy[9]

Physiotherapy Management[edit | edit source]

It is important to keep in mind the cause of rhabdomyolysis. It is important to not overexert the patient to prevent them from creating more muscle breakdown.  The most important thing is for the patient to retain range of motion as well as to properly hydrate.

The physical therapist treating a patient with rhabdomyolysis must make sure that the patient is not having any urinary problems which includes urine color.[10] Some interventions would include range of motion exercises (both active and passive), aerobic training, and gradual resistance training.[10]

In a recent study on rehabilitation for Rhabdomyolysis associated with breast cancer treatment, it was reported that physical activity such as strengthening and aerobic exercises were safe and beneficial to minimise immobility [11]. Exercise is crucial for reducing cancer-related fatigue, enhancing quality of life, and preventing unnecessarily long treatment wait times. It is preferable to take a holistic approach when treating a patient who is under intense physical and mental strain using Cognitive Behavioural Therapy (CBT). The settings for effective physical rehabilitation in aiding a person's improvement of independence, safety, and confidence were supplied by the coordination of transitions from acute care to in-patient rehabilitation in conjunction with holistic approach.

Exertional Rhabdomyolysis and Return to Sport[edit | edit source]


A client’s fitness level is extremely important when considering the development of a workout program. Exertional rhabdomyolysis may occur when a client is not accustomed to the mode or intensity of the exercise prescribed. Fitness professionals must understand the importance of initial fitness level and progressional overload so that the exercise stress challenges the client appropriately. Fitness specialists should also consider the risks when providing eccentric training in a hot environment or if the client has any genetic risk factors for rhabdomyolysis.

Physical Therapy Management Return to Sport[edit | edit source]

There is currently no evidence based guidelines for return to play after an episode of exertional rhabdomyolysis. However, a conservative return to sport protocol has been described by Consortium for Health and Military Performance (CHAMP) and is listed below.[12]

Returntosport.png [12]
Image Courtesy of David C. Tietze, M.D.

Schleich et al, outlined a phased reintegration program for safe and effective return to play post exertional rhabdomyolysis (table 1 below). Following phase IV, athletes in the study continued with agility work, speed development, and resistance training under the supervision of strength and conditioning staff. Each athletes return-to-play time will vary depending on severity of rhabdomyolysis, previous fitness level, training experience and maturation.

Table 1. Overview of Phased Return [13]
Phase 1: Activities  
Return to activities of daily living for 2 wk
Regular monitoring by athletic training staff
Screening for symptoms consistent with exertional rhabdomyolysis, sleep patterns, hydration, urine color, and class attendance
Monitoring of creatinine kinase and serum creatinine by primary care physician
Phase 2: Activities
Daily monitoring of hydration status, muscle soreness, and swelling
Initiation of physical activity: foam rolling, dynamic warm-up, aquatic jogging, and stretching
Phase 3: Activities
Daily monitoring of hydration status, muscle soreness, and swelling
Progression of physical activity: body-weight resistance movements, resistance training with elastic band, core training, stationary bicycling, and stretching
Phase 4: Activities
Daily monitoring of hydration status, muscle soreness, and swelling
Initiation of resistance training at 20%–25% of estimated 1-repetition maximum, agility exercises, and running
Risk stratification for recurrent rhabdomyolysis [14]
According to O’Connor et al., an athlete who experiences clinically relevant exertional rhabdomyolysis (ER) should first be risk-stratified as either low or high risk for a recurrence.
To be considered "suspicious for high risk,' at least one of the following conditions must exist or be present:
a. Delayed recovery (more than 1 wk) when activities have been restricted
b. Persistent elevation of CK (greater than five times the upper limit of the normal lab range) despite rest for at least 2 wk
c. ER complicated by acute renal injury of any degree
d. Personal or family history of ER
e. Personal or family history of recurrent muscle cramps or severe muscle pain that interferes with activities of daily living or sports performance
f. Personal or family history of malignant hyperthermia, or family history of unexplained complications or death following general anesthesia
g. Personal or family history of sickle cell disease or trait
h. Muscle injury after low to moderate work or activity
i. Personal history of significant heat injury (heat stroke)
j. Serum CK peak ≥ 100,000 U·L−1.
To be considered a "low risk" athlete, none of the high-risk conditions should exist, and at least one of the following conditions must exist or be present:
a. Rapid clinical recovery and CK normalization after exercise restrictions
b. Sufficiently fit or well trained athlete with a history of very intense training/exercise bout
c. No personal or family history of rhabdomyolysis or previous reporting of debilitating exercise-induced muscle pain, cramps, or heat injury
d. Existence of other group or team-related cases of ER during the same exercise sessions
e. Suspected or documented concomitant viral illness or infectious disease
f. Taking a drug or dietary supplement that could contribute to the development of ER
Complete history and physical examination should be completed and referral to experts for consideration of myopathic disorders before return to sport for any individual at high risk.
Prevention of recurrent episodes in pre-disposed individuals [15]
Regardless of cause:
• Avoid triggers
• Hydrate
• Warm-up before exercise
Fatty acid beta-oxidation:
• Low fat diet
• Replacement of essential fatty acids with walnut or soy oils
Vitamin D deficiency:
• Monitoring and normalization of vitamin D levels

Brief video regarding physical therapy management[16][17]

https://www.youtube.com/watch?v=NDdoiNNaMKI

Differential Diagnosis[edit | edit source]

Most Common Differential Diagnoses[18]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Health Direct Rhabdomyolysis Available: https://www.healthdirect.gov.au/rhabdomyolysis (accessed 17.9.2021)
  2. ↑ 2.0 2.1 2.2 2.3 Stanley M, Adigun R. Rhabdomyolysis. 2017 Available: https://www.statpearls.com/articlelibrary/viewarticle/28509/(accessed 17.9.2021)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Huerta-Alardin AL, Varon J, Marik P. Bench-to-beside review: Rhabdomyolysis - an overview for clinicians. Critical Care 2005; 9: 158-169
  4. ↑ 4.0 4.1 4.2 4.3 Vanholder R, Mehmet S, Erek E, Lameire N. Rhabdomyolysis. Journal of the American Society of Nephrology 2000; 1553-1561.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Efstratiadis G, Voulgaridou A, Nikiforou D, et al. Rhabdomyolysis updated. Hippokratia 2007; 11(3): 129-137.
  6. ↑ 6.0 6.1 6.2 6.3 Bagley WH, Yang H, Shah KH. Rhabdomyolysis. Intern Emergency Medicine 2007; 2: 210-218
  7. ↑ Savage DCL, Forbes M. Idiopathic Rhabdomyolysis. Archieves of Disease in Childhood 1971; 26: 594-607
  8. ↑ 8.0 8.1 WebMd Rhabdomyolysis Available: https://www.webmd.com/a-to-z-guides/rhabdomyolysis-symptoms-causes-treatments (accessed 17.9.2021)
  9. ↑ Khan F. Rhabdomyolysis: a review of the literature. The Netherlands Journal Of Medicine [serial online]. October 2009;67(9):272-283. Available from: MEDLINE, Ipswich, MA. Accessed March 23, 2014.
  10. ↑ 10.0 10.1 Brown T. Exertional Rhabdomyolysis: Early Recognition is Key. The Physician and Sports Medicine 2004; 32: 1-5
  11. ↑ Burns G, Wilson CM. Rehabilitation for Rhabdomyolysis Associated With Breast Cancer Treatment. Cureus. 2020 Jun 15;12(6).
  12. ↑ 12.0 12.1 Tietze DC, Borchers J. Exertional Rhabdomyolysis in the Athlete: A Clinical Review. Sports Health: A Multidisciplinary Approach. 2014;:1941738114523544.
  13. ↑ Schleich, K., Slayman, T., West, D. and Smoot, K. (2016). Return to Play After Exertional Rhabdomyolysis. Journal of Athletic Training, 51(5), pp.406-409.
  14. ↑ O'Connor, F., Brennan, F., Campbell, W., Heled, Y. and Deuster, P. (2008). Return to Physical Activity After Exertional Rhabdomyolysis. Current Sports Medicine Reports, 7(6), pp.328-331.
  15. ↑ Hannah-Shmouni F, McLeod K, Sirrs S. Recurrent exercise-induced rhabdomyolysis. CMAJ : Canadian Medical Association Journal. 2012;184(4):426-430. doi:10.1503/cmaj.110518.
  16. ↑ Schleich, K., Slayman, T., West, D. and Smoot, K. (2016). Return to Play After Exertional Rhabdomyolysis. Journal of Athletic Training, 51(5), pp.406-409.
  17. ↑ O'Connor, F., Brennan, F., Campbell, W., Heled, Y. and Deuster, P. (2008). Return to Physical Activity After Exertional Rhabdomyolysis. Current Sports Medicine Reports, 7(6), pp.328-331.
  18. ↑ Muscal E. Rhabdomyolysis: Differential Diagnoses and Workup. eMedicine 2009.
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