DISORDERS OF PROLONGED EXERTION

Dr Chris Ellis M Sc, MRCGP, MFSEM

General & Sports Practitioner, Kinlochleven.

“We

have

won.”

AND THEN HE DIED!

Pheidippides490 BC

Deaths in Great North Run may prompt review of advice for runners.

Andrew Culf, Sports CorrespondentThe Guardian, Tuesday 20 September, 2005.

Postmortem examinations were being held

yesterday to establish the cause of deaths of four

men who died while taking part in the BUPA Great

North Run, the world's largest half-marathon.

The four, aged between 28 and 52, collapsed in

separate incidents around the 13-mile course.

“It won’t happen to me.”

Marathon victim died from drinking too MUCH water.

London Evening Standard

24 April 2007

A 22-year-old man died after completing his first London

Marathon because he drank too much water.

SYSTEMIC LOCALISED

SUDDEN DEATH

• Cardiac arrest > 35yrs (post heart attack).

• Cardiac arrest < 35yrs (hereditary heart defect).

• Other medical disorders.

PHYSIOLOGICAL

(Extreme

variations of

normal).

• Exercise associated postural hypotension (EAPH).

• Exertional rise in temperature.

• Rhabdomyolysis (uncomplicated).

• Moderate weight loss (2-4%).

• Exertional low blood sugar/hypoglycaemia.

PATHOLOGICAL

(Abnormal/disease

states).

• Exercise associated low sodium/hyponatraemia (EAH).

• Dehydration/raised sodium.

• Rhabdomyolysis with complications (ARF).

• Heatstroke.

• Compartment syndrome.

• Stress fracture.

• Soft tissue infection.

• Blisters

EXERTIONAL DISORDERS FOR DISCUSSION TONIGHT.

SUDDEN (CARDIAC) DEATH.

• Rare.

• Usually (but not exclusively) cardiac.

• When cardiac, cause usually governed by age:

Under 35 years-Inherited cardiac defect.

Marc-Vivien Foe (Deceased)

Over 35 years-Diseased arteries

Jimmy Fixx (Deceased)

EXERCISE ASSOCIATED POSTURAL HYPOTENSION (EAPH).

Commonest cause of post-exertional collapse, over-treated and not recognised.

COLLAPSE: RULE OF THUMB

•Collapse shortly after finishing the race or a stage is usually EAPH if the runner finished symptom free.

•Collapse while running, or considerably after, is usually serious and needs medical assessment

Features:

•Immediately on stopping activity

•No prior or other symptoms

•Rapid spontaneous recovery

•No active treatment needed, just let lie and observe.

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

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

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

RACE NO. CK(<200). RACE NO. CK(<200). RACE NO. CK(<200).

63 12,174 124 8,429 67 7,365

42 4,756 135 30,243 126 29,837

145 7,528 49 17,097 80 14,603

7 8,357 48 9,276 78 14,952

99 8,735 50 2,584 26 3,209

54 5,536 44 3,897 37 9,909

11 19,487 121 26,723 6 1,124

108 11,485 27 14,773 71 50,347

5 19,790 132 7,147 127 13,547

56 3,902 40 13,169 84 3,501

141 12,553 86 3,565 120 65,724

22 10,066 34 17,695 103 68,852

150 26,345 31 4,925 122 14,738

90 6,346 75 15,029 55 13,864

62 6,582 148 17,697 113 42,670

94 7,711 130 2,354 21 27,277

144 3,644 29 25,671 20 1,499

118 7,648 128 6,371 1 6,624

101 2,924 38 6,765 109 8,060

41 9,171 2 2,800 81 132,645

19 2,793 70 10,530 134 29,490

111 5,257 67 7,365 79 19,310

52 13,309

RHABDOMYOLYSIS IS UNIVERSAL AND USUALLY INNOCENT.

Creatinine Kinase levels in 67 healthy WHWR 2009 finishers.Cuthill, Ellis & Panarelli.

% WEIGHT CHANGE IN 66 HEALTHY 2009 WHWR FINISHERS.Cuthill, Ellis & Panarelli.

% Wt.change.

-8

-6

-4

-2

0

2

4

6

WEIGHT LOSS (2-4%): Normal and ? desirable.

0

500

1000

1500

2000

2500

-8 -6 -4 -2 0 2

Tota

l p

erf

orm

an

ce t

ime

(m

inu

tes)

.

Body weight change (%).

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

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

Cuthill, Ellis, Panarelli & Sharwood.

WEIGHT LOSS: Statistically significant association with favourable performance.

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

EXERCISE ASSOCIATEDHYPONATRAEMIA (EAH).

David Rogers (Deceased), London Marathon, 2007

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

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

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

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

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

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

123

128

133

138

143

148

153

123

128

133

138

143

148

153

WHWR, 2009.n=66

WSER, 2009.n=47

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

*

*Pre-race sodium, 131. NOT EAH.

WHWR, 2009.(from 66 finishers tested.)

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

WSER, 2009.(from 47 finishers tested.)

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

• Generalised muscle breakdown and liberation of contents into body is universal and usually innocent.

• Occasionally becomes pathological (abnormal).

• Rhabdo symptoms.

Muscle pain. Dark urine. Lack of urine. Lack of well-being.

• Rhabdo complications.

Acute kidney (renal) failure (ARF), others, death.

• Rhabdo is real.

Two cases of ARF from WHWR since 2005.

• Rhabdo prevention.

Less preventable than EAH.

Anti-inflammatories and viral illness are risk factors.

Suspect early to minimise complications.

Report : chocolate or reduced urine & excessive muscle pains.

EXERTIONAL HEATSTROKE

Elevation of CORE temperature above 40 degrees, PLUS brain impairment.

• Exertional Heatstroke is NOT same as “hot”.

Exercise can cause the core temperature to rise without symptoms or significance.

• Exertional Heatstroke is rare. Not seen so far in WHWR.

• Exertional Heatstroke symptoms are initially vague.

Non-specific confusion/lack of well-being.

Mortality, once established, is high.

• Exertional Heatstroke causes.

Abnormal overproduction of heat by muscles with which body can’t deal.

A combination of, exercise, inherited disposition and further unknown trigger.

• Exertional heatstroke prevention.

Disposition if previous severe “heat reaction” to Anaesthetic or other prescribed or street drugs.

High suspicion needed. Treat early and aggressively and accept unneccessary treatment.

ACUTE COMPARTMENT SYNDROME

LocalisedLocalisedLocalisedLocalised swelling of muscle group, usually of leg, within enclosed sinew (fascia), following

injury or overuse and may be associated with constricting bandage or plaster cast.

This is an emergency and requires urgent surgical decompression.

SITE % OF

TOTAL

TIBIA 55

METATARSALS 23

FIBULA 14

Neck of Femur 4

Shaft of Femur 2

Pubic rami 2

Sacrum 0.1

Navicular

Cuboid

Patella

Sesamoids

Calcaneum

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

Soft tissue infection(“cellulitis”).

Blister

CONCLUSIONS

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

•Drink by thirst.

•Avoid NSAIDs.

•Monitor weight.

•Heat exhaustion doesn’t exist.

•Diagnose dehydration cautiously.

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

•Insist on blood tests.

•No iv fluids without first measuring sodium.

THANK YOU & QUESTIONS

EAPH

WT LOSS

TEMP RISE

MUSCLES ACHECK RISES

SALT LEVELSMAINTAINED

SUGAR LEVELSFALL

SUMMARY: Normal responses to prolonged exertion.