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

DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM. “We have won.”. Pheidippides: 490 BC. AND THEN HE DIED!. EXERTIONAL DISORDERS FOR DISCUSSION TONIGHT. CARDIAC ARREST/SUDDEN DEATH. Rare. Usually (but not exclusively) cardiac.

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

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  1. DISORDERS OF PROLONGED EXERTION. Dr Chris Ellis M Sc, MRCGP, MFSEM “We have won.” Pheidippides: 490 BC AND THEN HE DIED!

  2. EXERTIONAL DISORDERS FOR DISCUSSION TONIGHT.

  3. CARDIAC ARREST/SUDDEN DEATH. • Rare. • Usually (but not exclusively) cardiac. • When cardiac, cause usually governed by age: Under 35 years-Inherited cardiac defect. Over 35 years-Diseased arteries Marc-Vivien Foe (Deceased) Jimmy Fixx (Deceased)

  4. EXERCISE ASSOCIATED POSTURAL HYPOTENSION (EAPH). Commonest cause of post-exertional collapse, often over-treated and not recognised for what it is. • Features: • Immediately on stopping activity • No prior symptoms • Rapid spontaneous recovery • No active treatment needed, just let lie and observe. • 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

  5. 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.

  6. RHABDOMYOLYSIS IS UNIVERSAL AND USUALLY INNOCENT. Creatinine Kinase levels in 67 healthy WHWR 2009 finishers. Cuthill, Ellis & Panarelli.

  7. WEIGHT LOSS (2-4%): Normal and ? desirable. % WEIGHT CHANGE IN 66 HEALTHY 2009 WHWR FINISHERS. Cuthill, Ellis & Panarelli. % Wt. change.

  8. WEIGHT LOSS: Statistically significant association with favourable performance. COMPARATIVE DATA FROM WHWR AND SA IRONMAN WEIGHT CHANGE v. PERFORMANCE. Cuthill, Ellis, Panarelli & Sharwood. WHWR, 2009. SA Ironman Triathlon, 2001 & 2.

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

  10. 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. 4 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. EXERCISE ASSOCIATEDHYPONATRAEMIA (EAH). David Rogers (Deceased), London Marathon, 2007

  11. COMPARATIVE SODIUM LEVELS IN HEALTHY FINISHERS WHWR v. WSER, 2009. Cuthill, Ellis, Panarelli & Hew-Butler. * WHWR, 2009. n=66 WSER, 2009. n=47 *Pre-race sodium, 131. NOT EAH. • WSER, 2009. • (from 47 finishers tested.) • Asymptomatic Hyponatraemia (EAH) - 19. • Asymptomatic Hypernatraemia - Nil. • WHWR, 2009. • (from 66 finishers tested.) • Asymptomatic Hyponatraemia (EAH) - Nil. • Asymptomatic Hypernatraemia - 4.

  12. RHABDO MYOLYSIS • 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.

  13. EXERTIONAL HEATSTROKEElevation 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.

  14. ACUTE COMPARTMENT SYNDROME Localised 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.

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

  16. 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 sodium.

  17. THANK YOU & QUESTIONS

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