Rhabdomyolysis

Lauren Wu SPT
Spring 2018
What is Rhabdomyolysis?1

 Rhabdomyolysis (Rhabdo) is a destruction of muscle tissue

 Rhabdo = striated
 Myo = muscle
 Lysis = cell break down
 Other names
 Crush syndrome
 Meyer Betz disease
Pathophysiology1,2

 Normal process
 Breakdown of muscle fiber covering –
sarcolemma
 Myoglobin (and other intracellular
components) released in blood
 Kidneys filter out into urine

 Extreme injury – Rhabdo

 LARGE amount of myoglobin accumulates
and is NEPHROTOXIC
 Can lead to Acute Kidney Injury (AKI)
Prevalence

 26,000 cases of Rhabdo reported in the U.S. each year 3

 10-40% with Rhabdo develop ARF4
 7-10% of all cases of AKI are rhabdo complications2
 Adults: Men > Women
Typical Signs/Symptoms1

 General weakness, fatigue

 Swelling
 Discoloration, pallor
 Muscle pain, tenderness
 Paresthesia
 Dark brown urine (”cola” or
“tea” colored)
 Decreased urine output
 “Flu-like” symptoms
Typical Signs/Symptoms

Swelling
Typical Signs/Symptoms

Myoglobinuria
Typical Signs/Symptoms

Disseminated intravascular coagulation

Lab Findings3,5

Blood Electrolyte or Enzyme Change Normal Values

Potassium ↑ 3.5-5 mmol/L
Calcium ↓ 1.03-1.23 mmol/L
Phosphate ↑ .8-1.5 mmol/L
Creatine Phosphokinase ↑↑↑ (>5,000 25-200 U/L
(CPK)* U/L)
Lactate Dehydrogenase ↑ 50-150 U/L
Uric Acid ↑ .18-.48 mmol/L
pH ↓ 7.35-7.45
BUN ↑ 8-21 mg/dL
*Also known as Creatine Kinase (CK). May be elevated after heart attack, surgery, certain
medications. Can arise from cardiac, skeletal muscle, or brain. Rises 2-12 hr following
injury, peaks 24-72 hr, declines within 3-5 days
Lab Findings3,5

Urinalysis Change Normal Values

Color Brown Yellow - clear
Myoglobinuria ↑ (100 mg/dL) < .5-1.5 mg/dL
Dipstick test* (+) (-)
Amount ↓ (oliguria) 800 – 2000 mL/day
*May be (+) in presence of hematuria
Causes6

 Traumatic injury
 Exertion
 Muscle hypoxia
 Medication/Drug-induced
 Genetic disorders
 Infection
 Body temperature changes
 Metabolic and electrolyte disorders
 Idiopathic
Causes – Traumatic Injury6

 CRUSH Injuries
 “Crush syndrome”
 Documented in military history
 Bombings
 Natural Disasters
 Earthquakes
Causes – Exertion6

 STRENUOUS exercise
 Documented in military history
 Strenuous training
 Inappropriate training programs
 Some athletes
 Seizures
 Prolonged muscle activity
Causes – Muscle Hypoxia6

 COMPRESSION of limb
 Especially during prolonged
immobilization
 Long surgery, loss of
consciousness, coma, anesthesia
 Substance or ETOH abuse
 Major artery occlusions
 Contents become released once
compression is removed
Causes – Medication/Drug-induced6

 MEDICATIONS
 Statins may disrupt proteins for
myocyte maintenance
 SSRIs, neuroleptics, steroids
 ETOH and other drugs
 Direct toxicity to cells
 Cocaine, Meth
 Snake venom, insect venom
Causes – Others1,6
 Genetic Disorders
 Glycolysis or glycogenolysis
 Lipid metabolism
 Mitochondrial
 Infection
 Influenza A and B
 Viral Myositis
 Coxsackie virus
 Epstein-Barr
 HIV
 Legionella
 Extreme body temperature
 Heat stroke
 Malignant hyperthermia
 Malignant Neuroleptic syndrome
 Hypothermia
 Metabolic/Electrolyte
 Hypokalemia
 Hypocalcemia
 Diabetic Ketoacidosis
 McArdle’s Disease
 Idiopathic
Complications
 Hyperkalemia, hypocalcemia
 Cardiac arrest, cardiac arrhythmias
 Electrolyte replacement
 Hypovolemia
 Swelling - Extracellular fluid moves into injured tissue
 Leads to hypotension, shock, hypoperfusion of kidneys
 Fluid replacement
 AKI/ARF – 5 to 16.5% all cases
 Tubular necrosis
 Hemodialysis
 Compartment syndrome
 Nerve and vascular compression
 Surgical decompression, fasciotomy
 Death
 Sudden, even in healthy, young athletes
Prognosis2
 Severity
 The longer the delay in receiving treatment, the more severe AKI
 Excellent if caught early, treated aggressively
 Better outcomes in those without AKI
 Mortality varies depending on cause, setting
 32% – vasculopathy, limb ischemia
 3.4% - ETOH, drug abuse
 59% - of ICU patients with AKI
 22% - of ICU patients without AKI
 Depends on extent of kidney damage
 Most recover renal function
 80% long term survival
 Treatment varies; days to weeks
Implications for Physical Therapy?

 Prevention
 Education - Gradual exercise
progression, avoid
overexertion
 Appropriate training programs
 Proper hydration and electrolytes,
avoid exercising in extreme heat
conditions
Implications for Physical Therapy?

 Evaluation and Examination

 Thorough subjective, DDx
 DOMS? Special MSK tests? Flu-like symptoms?
 Hx of INTENSE exercise with
fatigue/soreness/pain/swelling?
 Medication? Urine?

 Check the chart

 Lab values, fluids, medical history

 RED FLAGS – dark urine

 May need to REFER
Implications for Physical Therapy?

 Know medical course of treatment

 Treat underlying cause!
 Early/aggressive fluid resuscitation
and electrolyte replacement
 Possible fasciotomy, dialysis
Implications for Physical Therapy?7

 Treatment after medical management

 No set protocol
 Gradual reconditioning

1. Regain ROM, muscle strength

2. Low intensity exercise, progressively
increasing duration to build endurance
3. Low intensity isometrics, progression with
resistance exercise
4. Normal exercise routine without pain
Questions?
References
1. Rhabdomyolysis. Physiopedia Web site. https://
www.physio-pedia.com/Rhabdomyolysis. Accessed February 25, 2018.
2. Bosch X, Poch E, Grau JP. Rhabdomyolysis and acute kidney injury. N
Engl J Med. 2009;361:62-72. doi: 10.1056/NEJMra0801327
3. Bagley WH, Yang H, Shah KH. Rhabdomyolysis. Intern Emerg Med.
2007;2(3):210-8. doi: 10.1007/s11739-007-0060-8
4. Torres PA, Helmstetter JA, Kaye AM, Kaye AD. Rhabdomyolysis:
Pathogenesis, diagnosis, and treatment. Oschsner J. 2015;15(1):58-69.
5. Rhabdomyolysis Workup. Medscape Web site. https://
emedicine.medscape.com/article/1007814-workup#c7. Updated
November 10, 2017. Accessed February 25, 2018.
6. Keltz E, Khan FY, Mann G. Rhabdomyolysis. The role of diagnostic and
prognostic factors. Muscles Ligaments Tendons J. 2013;3(4)303-312.
7. Baxter RE, Moore JH. Diagnosis and treatment of acute exertional
rhabdomyolysis. J Orthop Sports Phys Ther. 2003;33(3):104-8. doi:
10.2519/jospt.2003.33.3.104