Page 87 - Journal of Special Operations Medicine - Fall 2016

Table 2 Return-to-Duty Guidelines for Individuals at Lower supported by results of a randomized double-blinded
Risk for Recurrent of Exertional Rhabdomyolysis a placebo-controlled trial that indicated that a 7-day preex-
Phase 1 ercise and postexercise consumption of branched-chain
a. Rest for 72 hours and encourage oral hydration. amino acids reduced indices of muscle damage after an
exercise routine designed to induce exercise-induced
b. Sleep 8 hours consecutively, nightly. muscle damage. A recent meta-analysis, which did not
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c. Remain in thermally controlled environment if ER occurred include the previous study, concluded that there were
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in association with a heat injury. some limited data supporting a reduction in muscle sore-
d. Follow up in 72 hours for repeated CK measurement ness and markers of muscle damage when protein sup-
and UA. plements were consumed after daily training sessions. 62
e. When the CK value is <5 times the upper limit of the
laboratory normal range and the UA has returned to nor- It has been hypothesized that vitamin D deficiency may
mal, begin phase 2. Otherwise, remain in phase 1, and predispose to ER because of links to muscle myopa-
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return every 72 hours and repeat until CK is <5 times the thies and the fact that vitamin D increases ATP and
upper limit of the laboratory normal range and the UA 64,65
has returned to normal. protein synthesis. Although this hypothesis is highly
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f. If CK remains ≥5 times the laboratory upper limit of nor- speculative, vitamin D deficiency is common and in-
dividuals who do not get sufficient sun exposure may
mal and/or the UA is persistently abnormal for 2 weeks,
refer for expert consultation. consider vitamin D supplementation.
Phase 2 Because of the likelihood of ER increases at higher tem-
a. Begin light activities, no strenuous physical activities. peratures (as mentioned), rest and rehydration should be
b. Physical activity at own pace and distance. Follow up emphasized during training in those conditions. Work/
with care provider in 1 week. rest and proper rehydration schedules have been devel-
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c. If no return of clinical symptoms, then begin phase 3; oped for the military and are included in Table 3. Note
otherwise remain in phase 2 and return at 1-week inter- that there is a limit to the volume of fluids that should
vals. May progress to phase 3 when there is no significant be consumed, to avoid hyponatremia.
muscle weakness, swelling, pain, or soreness. If muscle
pain persists without objective findings beyond 4 weeks,
consider specialty evaluation to include psychiatry. Some dietary supplements have been implicated in cases
of ER. 53,68 Any supplement being contemplated should
Phase 3
be discussed with a knowledgeable healthcare provider.
a. Gradually return to regular physical training and sports CHAMP’s Human Performance Resource Center Op-
activities.
erational Supplement Safety website (http://hprc-online
b. Follow up with care provider as needed. .org/) is a resource to assess the risk of a particular sup-
CK, creatine kinase; ER, exertional rhabdomyolysis; UA, urinalysis. plement; an Ask-the-Expert capability also is available.
a Adapted from O’Connor et al. 48
One epidemiologic study found that football players Disclaimer
who consumed protein shakes were less likely to de- The views expressed in this presentation are those of the
velop ER after a very intense strength training work- authors and do not necessarily reflect the official policy
out, compared with those who did not. This study was of the Department of Defense, Department of the Army,
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Table 3 Work/Rest Ratios and Fluid Replacement Guidelines for Hot Weather Training 67
Easy Work a Moderate Work b Hard Work c
Work/Rest Water Intake Work/Rest Water Intake Work/Rest Water Intake
o
Heat Level WBGT ( F) (min) (qt/h) (min) (qt/h) (min) (qt/h)
1 78–82 No limit 0.50 No limit 0.75 40/20 0.75
2 82–85 No limit 0.50 50/10 0.75 30/30 1.00
3 85–88 No limit 0.75 40/20 0.75 30/30 1.00
4 88–90 No limit 0.75 30/30 0.75 20/40 1.00
5 >90 50/10 1.00 20/40 1.00 10/50 1.00
WBGT, wet bulb globe temperature
a Examples of easy work: weapons maintenance, walking 2.5 miles/hr with ≤30-lb load, drill and ceremony, manual of arms, marksmanship
training.
b Examples of moderate work: walking 3.5 miles/hr with ≤40-lb load, calisthenics, low/high crawl, defensive position construction, field assaults,
patrolling.
c Examples of hard work: Walking 3.5 miles/hr with >40-lb load, walking in loose sand at 2.5 miles/hr with load.

Exertional Rhabdomyolysis 69